Basic Information
| Provider Information | |||||||||
| NPI: | 1003106253 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARAB AMERICAN AND CHALDEAN COUNCIL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ACC - 7 MILE SITE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 62 W 7 MILE RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482031967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138936172 | ||||||||
| FaxNumber: | 3138930064 | ||||||||
| Practice Location | |||||||||
| Address1: | 34628 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483105233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869395016 | ||||||||
| FaxNumber: | 5865935194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2011 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SARAFA | ||||||||
| AuthorizedOfficialFirstName: | CARMEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3138936172 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ARAB AMERICAN AND CHALDEAN COUNCIL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MA, LPC | ||||||||
| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 251S00000X | MI | N | Agencies | Community/Behavioral Health | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0H28585 | 01 | MI | BCBS | OTHER | 3434247 | 05 | MI | MEDICAID |