Basic Information
| Provider Information | |||||||||
| NPI: | 1053468827 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WRAIKAT | ||||||||
| FirstName: | RIAD | ||||||||
| MiddleName: | MOH'D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 593 ROSEMARY ST | ||||||||
| Address2: | |||||||||
| City: | DEARBORN HTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481273627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135816592 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16904 W WARREN AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482283505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135817287 | ||||||||
| FaxNumber: | 3135817318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401001626 | MI | X | Behavioral Health & Social Service Providers | Counselor | Professional | 103T00000X | 6301013282 | MI | X | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 3434247 | 05 | MI | MEDICAID |