Provider Demographics
NPI:1649322181
Name:PIETROFESA, JOHN JOSEPH (EDD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:PIETROFESA
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48303-0099
Mailing Address - Country:US
Mailing Address - Phone:248-646-0821
Mailing Address - Fax:
Practice Address - Street 1:74 W LONG LAKE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-2769
Practice Address - Country:US
Practice Address - Phone:248-642-6066
Practice Address - Fax:248-642-5739
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005293103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
039078OtherVALUE OPTIONS
MIR67143Medicare UPIN
MI0F34738Medicare ID - Type Unspecified