Healthcare Provider Details

I. General information

NPI: 1407356371
Provider Name (Legal Business Name): MUHAMMAD ADAM BASSIOUNY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2018
Last Update Date: 02/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8311 ROOSEVELT RD
FOREST PARK IL
60130-2529
US

IV. Provider business mailing address

808 RIDGE DR APT 209
DEKALB IL
60115-1365
US

V. Phone/Fax

Practice location:
  • Phone: 708-771-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178011838
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: