Healthcare Provider Details

I. General information

NPI: 1972955631
Provider Name (Legal Business Name): BOUHARB COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 DUNDEE DR
WARREN MI
48092-1038
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 210-379-1101
  • Fax: 210-379-1101
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401013620
License Number StateMI

VIII. Authorized Official

Name: MARY BETH HOUPT
Title or Position: BILLING/CREDENTIALING
Credential:
Phone: 517-676-9788