Healthcare Provider Details

I. General information

NPI: 1790823359
Provider Name (Legal Business Name): ANGELA LAURA BUCCCIARELLI PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 W ANN ARBOR TRL STE 200
PLYMOUTH MI
48170-1631
US

IV. Provider business mailing address

2707 GRAVEL RIDGE DR
ROCHESTER HILLS MI
48307-4647
US

V. Phone/Fax

Practice location:
  • Phone: 734-414-7056
  • Fax: 734-414-9925
Mailing address:
  • Phone: 586-731-4724
  • Fax: 586-731-4724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: