Healthcare Provider Details

I. General information

NPI: 1942883020
Provider Name (Legal Business Name): PRISCILLA GEBRAYEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date: 04/28/2022
Reactivation Date: 09/13/2022

III. Provider practice location address

26300 W OUTER DR.
LINCOLN PARK MI
48146
US

IV. Provider business mailing address

26300 W OUTER DR.
LINCOLN PARK MI
48146
US

V. Phone/Fax

Practice location:
  • Phone: 313-388-4630
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851115422
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: