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General NPI Number Information
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NPI Number | 1790129518
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Entity Type | Individual
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Provider Name | WANDA ELAINE PETTWAY-NORRIS LLMSW
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Gender | Female
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Dates
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Enumeration Date | 04/23/2013
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Last Update Date | 08/15/2019
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Provider Practice Location Address
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Address Line | 13101 ALLEN RD
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City | SOUTHGATE
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State | MI
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Zip | 48195-2216
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Country | US
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Telephone | 734-785-7700
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Fax |
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Provider Business Mailing Address
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Address Line | 10351 DARTMOUTH ST
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City | OAK PARK
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State | MI
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Zip | 48237-1705
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Country | US
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Telephone | 248-242-0453
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 6801099255
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License Number State | MI
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