Provider Demographics
NPI:1194472209
Name:DEFAY- MARRERO, ANGEL MATEO
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:MATEO
Last Name:DEFAY- MARRERO
Suffix:
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:517-657-2638
Mailing Address - Fax:
Practice Address - Street 1:5281 W MAPLE RD.
Practice Address - Street 2:UNIT 195
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322
Practice Address - Country:US
Practice Address - Phone:844-244-4832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI1194472209106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician