Healthcare Provider Details

I. General information

NPI: 1497263065
Provider Name (Legal Business Name): NICHOLAS KHOURY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 12/26/2019
Certification Date: 12/26/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8062 ORTONVILLE RD
CLARKSTON MI
48348-4456
US

IV. Provider business mailing address

3148 SERENITY CT
OAKLAND MI
48363-2733
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-2970
  • Fax:
Mailing address:
  • Phone: 248-635-0231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401016309
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: