Healthcare Provider Details

I. General information

NPI: 1376483057
Provider Name (Legal Business Name): TAJ O GHANEM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18800 HUBBARD DR
DEARBORN MI
48126-4305
US

IV. Provider business mailing address

18800 HUBBARD DR
DEARBORN MI
48126-4305
US

V. Phone/Fax

Practice location:
  • Phone: 734-252-5215
  • Fax: 734-822-0237
Mailing address:
  • Phone: 735-252-5215
  • Fax: 734-882-0237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: