Provider Demographics
NPI:1174698179
Name:NOVELLI-CANNER, ADRIANA ESTELA (PT)
Entity type:Individual
Prefix:MRS
First Name:ADRIANA
Middle Name:ESTELA
Last Name:NOVELLI-CANNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3160 HAGGERTY RD
Mailing Address - Street 2:STE I
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2000
Mailing Address - Country:US
Mailing Address - Phone:248-669-5757
Mailing Address - Fax:248-669-2090
Practice Address - Street 1:3160 HAGGERTY RD
Practice Address - Street 2:STE H
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2000
Practice Address - Country:US
Practice Address - Phone:248-669-5757
Practice Address - Fax:248-669-2090
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F35754OtherBCBS OF MI PROVIDER ID