Provider Demographics
NPI:1790129518
Name:PETTWAY-NORRIS, WANDA ELAINE (LLMSW)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:ELAINE
Last Name:PETTWAY-NORRIS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10351 DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1705
Mailing Address - Country:US
Mailing Address - Phone:248-242-0453
Mailing Address - Fax:
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801099255104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1234567OtherBLUE CROSS BLUE SHIELD