Provider Demographics
NPI:1467529503
Name:WUCETICH, NANCY LYNN (LMSW, ACSW)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:LYNN
Last Name:WUCETICH
Suffix:
Gender:F
Credentials:LMSW, ACSW
Other - Prefix:MS
Other - First Name:NANCY
Other - Middle Name:LYNN
Other - Last Name:WEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSW, LMSW
Mailing Address - Street 1:2351 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-1826
Mailing Address - Country:US
Mailing Address - Phone:248-544-4004
Mailing Address - Fax:248-544-4113
Practice Address - Street 1:2351 12 MILE RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1826
Practice Address - Country:US
Practice Address - Phone:248-544-4006
Practice Address - Fax:248-544-4113
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010119911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1883825Medicaid
MI0F37164Medicare ID - Type Unspecified