Healthcare Provider Details

I. General information

NPI: 1043125172
Provider Name (Legal Business Name): MELLAK ALKANANI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 AUTO CLUB DR
DEARBORN MI
48126-2749
US

IV. Provider business mailing address

5111 AUTO CLUB DR
DEARBORN MI
48126-2749
US

V. Phone/Fax

Practice location:
  • Phone: 313-406-5056
  • Fax:
Mailing address:
  • Phone: 313-406-5056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberA900001940082
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: