Provider Demographics
NPI:1922140490
Name:PETRICCA, MARIE C (MSW ACSW CACI LMSW)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:C
Last Name:PETRICCA
Suffix:
Gender:F
Credentials:MSW ACSW CACI LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20382 VAN BORN RD
Mailing Address - Street 2:CATHOLIC SOCIAL SERVICES OF WAYNE COUNTY
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48125
Mailing Address - Country:US
Mailing Address - Phone:313-792-9286
Mailing Address - Fax:313-792-0444
Practice Address - Street 1:20382 VAN BORN ROAD
Practice Address - Street 2:CATHOLIC SOCIAL SERVICES OF WAYNE COUNTY
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48125
Practice Address - Country:US
Practice Address - Phone:313-792-9286
Practice Address - Fax:313-792-0444
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010179151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI33Medicare ID - Type Unspecified