Healthcare Provider Details

I. General information

NPI: 1467181792
Provider Name (Legal Business Name): NICHOLAS PITUCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12851 GRAND RIVER RD
BRIGHTON MI
48116-8506
US

IV. Provider business mailing address

12851 GRAND RIVER RD
BRIGHTON MI
48116-8506
US

V. Phone/Fax

Practice location:
  • Phone: 810-227-1211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851114660
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: