Healthcare Provider Details

I. General information

NPI: 1396101069
Provider Name (Legal Business Name): MANAL HAZIME
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2016
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24736 MICHIGAN AVE
DEARBORN MI
48124-1750
US

IV. Provider business mailing address

24736 MICHIGAN AVE
DEARBORN MI
48124-1750
US

V. Phone/Fax

Practice location:
  • Phone: 313-615-6825
  • Fax:
Mailing address:
  • Phone: 313-615-6825
  • Fax: 347-338-2164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401015069
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: