Healthcare Provider Details

I. General information

NPI: 1083257067
Provider Name (Legal Business Name): LENA AZZAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34841 VETERANS PLZ
WAYNE MI
48184-1733
US

IV. Provider business mailing address

34841 VETERANS PLZ
WAYNE MI
48184-1733
US

V. Phone/Fax

Practice location:
  • Phone: 313-292-7640
  • Fax: 313-292-9270
Mailing address:
  • Phone: 313-292-7640
  • Fax: 313-292-9270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401017730
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401222304
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: