Provider Demographics
NPI:1558851626
Name:DELRIDGE, DORETHIA
Entity Type:Individual
Prefix:
First Name:DORETHIA
Middle Name:
Last Name:DELRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27329 HOOVER RD APT 20
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-4537
Mailing Address - Country:US
Mailing Address - Phone:586-420-0880
Mailing Address - Fax:
Practice Address - Street 1:17141 RYAN RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48212-1112
Practice Address - Country:US
Practice Address - Phone:313-531-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511107491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical