Basic Information
| Provider Information | |||||||||
| NPI: | 1760812820 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAMMOUDEH | ||||||||
| FirstName: | KRISTINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 PARKLANE BLVD | ||||||||
| Address2: | SUITE 695 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481262696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132718170 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6 PARKLANE BLVD | ||||||||
| Address2: | SUITE 695 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481262696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132718170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2013 | ||||||||
| LastUpdateDate: | 11/26/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301014382 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6301014382 | 01 | MI | LICENCE | OTHER |