Healthcare Provider Details

I. General information

NPI: 1194243493
Provider Name (Legal Business Name): INTITHAR ALISSAWI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6452 SCHAEFER RD
DEARBORN MI
48126-2213
US

IV. Provider business mailing address

8730 RANDY DR
WESTLAND MI
48185-1758
US

V. Phone/Fax

Practice location:
  • Phone: 313-759-1507
  • Fax:
Mailing address:
  • Phone: 313-759-1507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401001365
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBEH-001998
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: