Provider Demographics
NPI:1144207424
Name:IANNI, PETER (PHD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:IANNI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32905 TWELVE MILE RD
Mailing Address - Street 2:STE 130
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3343
Mailing Address - Country:US
Mailing Address - Phone:248-553-4888
Mailing Address - Fax:248-553-3601
Practice Address - Street 1:32905 TWELVE MILE RD
Practice Address - Street 2:STE 130
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3343
Practice Address - Country:US
Practice Address - Phone:248-553-4888
Practice Address - Fax:248-553-3601
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2011-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005479103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
132988200OtherDEPARTMENT OF LABOR
P00088254OtherRAILROAD MEDICARE
0F34872Medicare ID - Type Unspecified