Healthcare Provider Details

I. General information

NPI: 1245908151
Provider Name (Legal Business Name): KAMAL TAYMOUR GHAZI LLMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 03/01/2022
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE LIFEWAYS
JACKSON MI
49202
US

IV. Provider business mailing address

109 GARRISON DR
BROOKLYN MI
49230-9711
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-1200
  • Fax:
Mailing address:
  • Phone: 517-745-6228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: