MEDICARE: MR. ANGELO D PHARR II

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	:	1235796772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANGELO D PHARR II

Provider Business Mailing Address
First Line	:	15606 E 7 MILE RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-2557
Country	:	US
Telephone Number	:	313-401-2243
Fax Number	:

Provider Business Practice Location Address
First Line	:	15606 E 7 MILE RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-2557
Country	:	US
Telephone Number	:	313-401-2243
Fax Number	:

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

Provider Enumeration Date	:	05/21/2019
Last Update Date	:	05/21/2019

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