Provider Demographics
NPI:1073059713
Name:PERRAULT, ANN
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:PERRAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1227
Mailing Address - Country:US
Mailing Address - Phone:313-806-1637
Mailing Address - Fax:
Practice Address - Street 1:4835 2ND AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1227
Practice Address - Country:US
Practice Address - Phone:313-806-1637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7201008129225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist