Healthcare Provider Details

I. General information

NPI: 1134556749
Provider Name (Legal Business Name): LOUELLA CANTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18269 APPOLINE ST
DETROIT MI
48235-1451
US

IV. Provider business mailing address

18269 APPOLINE ST
DETROIT MI
48235-1451
US

V. Phone/Fax

Practice location:
  • Phone: 248-236-5353
  • Fax: 248-236-5354
Mailing address:
  • Phone: 248-236-5353
  • Fax: 248-236-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberL2574
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: