Provider Demographics
NPI:1245800705
Name:VERNON, DE'ANGELO
Entity Type:Individual
Prefix:
First Name:DE'ANGELO
Middle Name:
Last Name:VERNON
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 1:13101 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2216
Mailing Address - Country:US
Mailing Address - Phone:734-785-7705
Mailing Address - Fax:
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851109642104100000X
MI68011096421041C0700X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical