Provider Demographics
NPI:1578778692
Name:ETTEMA, JANELLE CAYO (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:JANELLE
Middle Name:CAYO
Last Name:ETTEMA
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 E GRAND RIVER AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-6584
Mailing Address - Country:US
Mailing Address - Phone:517-548-1869
Mailing Address - Fax:517-258-3000
Practice Address - Street 1:3075 E GRAND RIVER AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-6584
Practice Address - Country:US
Practice Address - Phone:517-548-1869
Practice Address - Fax:517-258-3000
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010420103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680D710410Medicare UPIN
MI680D711600Medicare UPIN