Provider Demographics
NPI:1316369937
Name:PETRUSAK, JUSTIN DAVID (LMSW)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:DAVID
Last Name:PETRUSAK
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9428 MCDOUGALL ST FL 2
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3564
Mailing Address - Country:US
Mailing Address - Phone:586-214-4019
Mailing Address - Fax:
Practice Address - Street 1:4756 CASS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2357
Practice Address - Country:US
Practice Address - Phone:313-577-4409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010903561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical