Provider Demographics
NPI:1750886602
Name:PANTOLEON, ILIANA (TLLP)
Entity type:Individual
Prefix:MRS
First Name:ILIANA
Middle Name:
Last Name:PANTOLEON
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29476 BOBRICH ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3404
Mailing Address - Country:US
Mailing Address - Phone:248-946-9351
Mailing Address - Fax:
Practice Address - Street 1:650 GRISWOLD ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1666
Practice Address - Country:US
Practice Address - Phone:248-912-0080
Practice Address - Fax:248-912-0208
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017023103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist