Provider Demographics
NPI:1245383736
Name:NANCY RIETDORF PHD PLLC
Entity Type:Organization
Organization Name:NANCY RIETDORF PHD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:RIETDORF
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:810-985-8000
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301004023103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P44500Medicare ID - Type Unspecified
MIS16700Medicare UPIN