Basic Information
| Provider Information | |||||||||
| NPI: | 1417363730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ASFAR | ||||||||
| FirstName: | OLIVIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LLP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BAHOORA | ||||||||
| OtherFirstName: | OLIVIA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | LLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6549 TOWN CENTER DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483464824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486206400 | ||||||||
| FaxNumber: | 2486206405 | ||||||||
| Practice Location | |||||||||
| Address1: | 6549 TOWN CENTER DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486206400 | ||||||||
| FaxNumber: | 2486206405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2014 | ||||||||
| LastUpdateDate: | 04/30/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301015666 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 6361005548 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.