Provider Demographics
NPI:1740434471
Name:CANINE, JOHN DAVID (EDD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:CANINE
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:936 S BALDWIN RD
Mailing Address - Street 2:102
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-3695
Mailing Address - Country:US
Mailing Address - Phone:248-814-0706
Mailing Address - Fax:248-814-0710
Practice Address - Street 1:936 S BALDWIN RD
Practice Address - Street 2:102
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-3695
Practice Address - Country:US
Practice Address - Phone:248-814-0706
Practice Address - Fax:248-814-0710
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361001384101YM0800X, 103TC0700X
103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty