Healthcare Provider Details

I. General information

NPI: 1255973343
Provider Name (Legal Business Name): ANNA ANGELO BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30503 GREENFIELD RD
SOUTHFIELD MI
48076-1594
US

IV. Provider business mailing address

3157 EVERGREEN DR
ROYAL OAK MI
48073-3234
US

V. Phone/Fax

Practice location:
  • Phone: 586-382-0933
  • Fax:
Mailing address:
  • Phone: 586-382-0933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-90472
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: