Provider Demographics
NPI:1295018075
Name:PIETRUS, MICHAEL R (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:PIETRUS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S MICHIGAN AVE
Mailing Address - Street 2:SUITE 707
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1308
Mailing Address - Country:US
Mailing Address - Phone:312-869-9401
Mailing Address - Fax:
Practice Address - Street 1:410 S MICHIGAN AVE
Practice Address - Street 2:SUITE 707
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-1308
Practice Address - Country:US
Practice Address - Phone:312-869-9401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008203103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist