Provider Demographics
NPI:1033192794
Name:RIETDORF, NANCY A (PHD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:A
Last Name:RIETDORF
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 STABLE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:KIMBALL
Mailing Address - State:MI
Mailing Address - Zip Code:48074-1441
Mailing Address - Country:US
Mailing Address - Phone:810-985-8000
Mailing Address - Fax:810-985-8044
Practice Address - Street 1:2837 STABLE DR
Practice Address - Street 2:SUITE B
Practice Address - City:KIMBALL
Practice Address - State:MI
Practice Address - Zip Code:48074-1441
Practice Address - Country:US
Practice Address - Phone:810-985-8000
Practice Address - Fax:810-985-8044
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301004023103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S16700Medicare UPIN
MI0P44500Medicare ID - Type Unspecified