Provider Demographics
NPI:1922711142
Name:CANTRELL, PRUDENCE
Entity Type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 KINGSBURY ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-1755
Mailing Address - Country:US
Mailing Address - Phone:313-595-1153
Mailing Address - Fax:
Practice Address - Street 1:7401 KINGSBURY ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-1755
Practice Address - Country:US
Practice Address - Phone:313-595-1153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty