Provider Demographics
NPI:1386841807
Name:DIETRICH, NANCY DOLIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:DOLIN
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:NANCY
Other - Middle Name:DOLIN
Other - Last Name:DIETRICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:575 PILGRIM AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1210
Mailing Address - Country:US
Mailing Address - Phone:248-885-1044
Mailing Address - Fax:
Practice Address - Street 1:999 HAYNES ST STE 300
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6775
Practice Address - Country:US
Practice Address - Phone:248-723-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801013713104100000X
MI6301012590103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker