Provider Demographics
NPI:1912959479
Name:WIETRZYKOWSKI, PAULA KATHLEEN (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:KATHLEEN
Last Name:WIETRZYKOWSKI
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 1:6050 N US HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:FREE SOIL
Mailing Address - State:MI
Mailing Address - Zip Code:49411-9157
Mailing Address - Country:US
Mailing Address - Phone:231-757-1260
Mailing Address - Fax:231-757-1261
Practice Address - Street 1:6050 N US HIGHWAY 31
Practice Address - Street 2:
Practice Address - City:FREE SOIL
Practice Address - State:MI
Practice Address - Zip Code:49411-9157
Practice Address - Country:US
Practice Address - Phone:231-757-1260
Practice Address - Fax:231-757-1261
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801081581104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0897371OtherBLUE CROSS BLUE SHIELD
MI383322171OtherTAX ID
MI0897371OtherBLUE CROSS BLUE SHIELD