Provider Demographics
NPI:1639725849
Name:RISTICH, NANCY ELLEN (LMSW)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ELLEN
Last Name:RISTICH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 PLEASANT MANOR DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-4302
Mailing Address - Country:US
Mailing Address - Phone:248-830-2153
Mailing Address - Fax:
Practice Address - Street 1:4000 W WALTON BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-4191
Practice Address - Country:US
Practice Address - Phone:248-461-6266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MI68010865491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical