Provider Demographics
NPI:1205537008
Name:MICHAEL, CLEANTHIS (BSC, TLLP)
Entity type:Individual
Prefix:MR
First Name:CLEANTHIS
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:BSC, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 ASTOR AVE APT 1923
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6161
Mailing Address - Country:US
Mailing Address - Phone:919-321-7574
Mailing Address - Fax:
Practice Address - Street 1:500 E WASHINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2057
Practice Address - Country:US
Practice Address - Phone:734-764-3471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000816390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program