Healthcare Provider Details

I. General information

NPI: 1790273415
Provider Name (Legal Business Name): AIDA R NASR LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 E WARREN AVE
DETROIT MI
48215-2061
US

IV. Provider business mailing address

4567 WESTLAND ST
DEARBORN MI
48126-2834
US

V. Phone/Fax

Practice location:
  • Phone: 313-824-8000
  • Fax:
Mailing address:
  • Phone: 313-952-4676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801101289
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: