Healthcare Provider Details

I. General information

NPI: 1417755158
Provider Name (Legal Business Name): MR. HASSAN KOUBAYSSI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 FIRESTONE ST
DEARBORN MI
48126-4602
US

IV. Provider business mailing address

153 BAY 26TH ST APT 3G
BROOKLYN NY
11214-4996
US

V. Phone/Fax

Practice location:
  • Phone: 313-470-1860
  • Fax:
Mailing address:
  • Phone: 929-592-6330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6362010097
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: