Provider Demographics
NPI:1902869233
Name:PETRIDES, NANCY DAHMS (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:DAHMS
Last Name:PETRIDES
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:NANCY
Other - Middle Name:LYNNE
Other - Last Name:DAHMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:37799 PROFESSIONAL CENTER DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154
Mailing Address - Country:US
Mailing Address - Phone:248-343-4695
Mailing Address - Fax:
Practice Address - Street 1:37799 PROFESSIONAL CENTER DR
Practice Address - Street 2:SUITE 106
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154
Practice Address - Country:US
Practice Address - Phone:248-343-4695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801033601104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON96600Medicare ID - Type Unspecified
ON13060Medicare ID - Type Unspecified