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NPI Code Detail

MEDICARE: MR. MARK CANNIZZARO PHD

MEDICARE: MR. MARK CANNIZZARO PHD
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
1103T00000XPsychologist6301012725MI

General Provider Information

NPI Number : 1144373812
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MARK CANNIZZARO PHD
Provider Business Mailing Address
First Line : 120 N WASHINGTON SQ STE 300
Second Line :
City : LANSING
State : MI
Zip : 48933-1658
Country : US
Telephone Number : 734-210-1854
Fax Number : 517-627-1289
Provider Business Practice Location Address
First Line : 120 N WASHINGTON SQ STE 300
Second Line :
City : LANSING
State : MI
Zip : 48933-1658
Country : US
Telephone Number : 734-210-1854
Fax Number : 517-627-1289
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/18/2007
Last Update Date : 03/13/2020

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