Healthcare Provider Details

I. General information

NPI: 1033682000
Provider Name (Legal Business Name): SALIM YACOUB LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 WALTON BLVD STE 60
ROCHESTER HILLS MI
48309-1729
US

IV. Provider business mailing address

27106 LARCHMONT ST
SAINT CLAIR SHORES MI
48081-3435
US

V. Phone/Fax

Practice location:
  • Phone: 248-608-4514
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401019825
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: