Provider Demographics
NPI:1164511929
Name:ZETUSKY, WALTER J (PHD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:J
Last Name:ZETUSKY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33135 SCHOOLCRAFT ROAD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1625
Mailing Address - Country:US
Mailing Address - Phone:734-425-0700
Mailing Address - Fax:734-425-9666
Practice Address - Street 1:33135 SCHOOLCRAFT ROAD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1625
Practice Address - Country:US
Practice Address - Phone:734-425-0700
Practice Address - Fax:734-425-9666
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006416103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OP23530Medicare ID - Type Unspecified
R66866Medicare UPIN