Provider Demographics
NPI:1184100091
Name:TSERTOS, NICOLLE
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:
Last Name:TSERTOS
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 1:465 W GOULSON AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-1770
Mailing Address - Country:US
Mailing Address - Phone:248-295-1258
Mailing Address - Fax:
Practice Address - Street 1:1200 N TELEGRAPH RD BLDG 32E
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1032
Practice Address - Country:US
Practice Address - Phone:248-464-6055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker