Healthcare Provider Details

I. General information

NPI: 1164526380
Provider Name (Legal Business Name): AMIR EXECUTIVES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19111 WEST TEN MILE ROAD SUITE 203
SOUTHFIELD MI
48075-2443
US

IV. Provider business mailing address

19111 WEST TEN MILE ROAD SUITE 203
SOUTHFIELD MI
48075-2443
US

V. Phone/Fax

Practice location:
  • Phone: 248-945-0200
  • Fax: 248-945-0204
Mailing address:
  • Phone: 248-945-0200
  • Fax: 248-945-0204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401001831
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801062749
License Number StateMI

VIII. Authorized Official

Name: DR. ALLEN CUSHINGBERRY
Title or Position: CEO
Credential: PSY.D.
Phone: 248-945-0200