Provider Demographics
NPI:1073162988
Name:CANNELLA, PETER JOHN JR
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOHN
Last Name:CANNELLA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W GREENLAWN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-2889
Mailing Address - Country:US
Mailing Address - Phone:517-657-9220
Mailing Address - Fax:248-712-4381
Practice Address - Street 1:405 W GREENLAWN AVE STE 200
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2889
Practice Address - Country:US
Practice Address - Phone:517-657-9220
Practice Address - Fax:248-712-4381
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst