Healthcare Provider Details

I. General information

NPI: 1063233351
Provider Name (Legal Business Name): SUHAN A IDRISS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 WALNUT ST
YPSILANTI MI
48198-3937
US

IV. Provider business mailing address

1122 WALNUT ST
YPSILANTI MI
48198-3937
US

V. Phone/Fax

Practice location:
  • Phone: 734-252-5215
  • Fax: 734-822-0237
Mailing address:
  • Phone: 734-252-5215
  • Fax: 734-822-0237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: