Healthcare Provider Details

I. General information

NPI: 1558704395
Provider Name (Legal Business Name): RENEE LYNN STROTHMAN PETKOVICH TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 GLENDALE CT
MONROE MI
48162-2605
US

IV. Provider business mailing address

19805 FARMINGTON RD
LIVONIA MI
48152-1444
US

V. Phone/Fax

Practice location:
  • Phone: 734-790-0701
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6361007547
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: