Provider Demographics
NPI:1134556749
Name:CANTY, LOUELLA
Entity type:Individual
Prefix:
First Name:LOUELLA
Middle Name:
Last Name:CANTY
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 1:18269 APPOLINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1451
Mailing Address - Country:US
Mailing Address - Phone:248-236-5353
Mailing Address - Fax:248-236-5354
Practice Address - Street 1:18269 APPOLINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1451
Practice Address - Country:US
Practice Address - Phone:248-236-5353
Practice Address - Fax:248-236-5354
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-27
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2574172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver