Provider Demographics
NPI:1184142960
Name:DEANGELIS, GARRETT CHARLES
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:CHARLES
Last Name:DEANGELIS
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 1:20330 ONEIDA DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-4459
Mailing Address - Country:US
Mailing Address - Phone:586-610-0220
Mailing Address - Fax:
Practice Address - Street 1:20330 ONEIDA DR
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-4459
Practice Address - Country:US
Practice Address - Phone:586-610-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer