MEDICARE: MR. PETER JOHN CANNELLA JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1073162988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETER JOHN CANNELLA JR.

Provider Business Mailing Address
First Line	:	405 W GREENLAWN AVE STE 200
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48910-2889
Country	:	US
Telephone Number	:	517-657-9220
Fax Number	:	248-712-4381

Provider Business Practice Location Address
First Line	:	405 W GREENLAWN AVE STE 200
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48910-2889
Country	:	US
Telephone Number	:	517-657-9220
Fax Number	:	248-712-4381

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2019
Last Update Date	:	04/07/2022

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