Provider Demographics
NPI:1437121381
Name:DI LORETO, ADOLPH OTTO (PHD)
Entity Type:Individual
Prefix:DR
First Name:ADOLPH
Middle Name:OTTO
Last Name:DI LORETO
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 1:352 BLUE STAR HWY
Mailing Address - Street 2:BLUE STAR PROFESSIONAL BLDG
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-7102
Mailing Address - Country:US
Mailing Address - Phone:269-637-1170
Mailing Address - Fax:269-639-1312
Practice Address - Street 1:352 BLUE STAR HWY
Practice Address - Street 2:BLUE STAR PROFESSIONAL BLDG
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-7102
Practice Address - Country:US
Practice Address - Phone:269-637-1170
Practice Address - Fax:269-639-1312
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-05
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0822103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR67129Medicare UPIN
MI0N95680Medicare ID - Type Unspecified