Provider Demographics
NPI:1174349260
Name:DECERCHIO, MIA A
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:A
Last Name:DECERCHIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1376 PEMBROKE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-2653
Mailing Address - Country:US
Mailing Address - Phone:248-520-8758
Mailing Address - Fax:
Practice Address - Street 1:30301 NORTHWESTERN HWY STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3278
Practice Address - Country:US
Practice Address - Phone:248-549-4339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-23
Last Update Date:2024-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI262603067927374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician