Basic Information
| Provider Information | |||||||||
| NPI: | 1992992093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGNELLO | ||||||||
| FirstName: | JEANNETTE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA., L.L.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AGME;;P | ||||||||
| OtherFirstName: | KEAM | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA., L.L.P. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5776 CELICO LN | ||||||||
| Address2: | |||||||||
| City: | DRYDEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484289201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866629600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1424 E 11 MILE RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480672026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485484044 | ||||||||
| FaxNumber: | 2485489239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2007 | ||||||||
| LastUpdateDate: | 08/19/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301013681 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 6301013681 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.