=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295524502
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN IBRAHIM MSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2025
-----------------------------------------------------
Last Update Date | 05/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29551 GREENFIELD RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-2249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-974-6565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4167 HOWARD ST
-----------------------------------------------------
City | LINCOLN PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48146-4066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 226-788-1169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6851096271
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------