Basic Information
Provider Information | |||||||||
NPI: | 1356630651 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ARAB AMERICAN AND CHALDEAN COUNCIL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ACC - WARREN SITE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 62 W. 7 MILE RD | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482031967 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3138936172 | ||||||||
FaxNumber: | 3138930064 | ||||||||
Practice Location | |||||||||
Address1: | 13840 W WARREN AVE | ||||||||
Address2: |   | ||||||||
City: | DEARBORN | ||||||||
State: | MI | ||||||||
PostalCode: | 481261425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3135817287 | ||||||||
FaxNumber: | 3135817318 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2011 | ||||||||
LastUpdateDate: | 09/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
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: | 09/02/2021 |
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 | 3434247 | 05 | MI |   | MEDICAID | 0H28585 | 01 | MI | BCBS | OTHER |