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General NPI Number Information
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NPI Number | 1396401543
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Entity Type | Organization
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Legal Business Name | WAVE MEDICAL CENTER PLLC
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Dates
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Enumeration Date | 11/11/2021
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Last Update Date | 11/13/2021
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Provider Practice Location Address
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Address Line | 17600 W WARREN AVE
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City | DETROIT
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State | MI
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Zip | 48228-3509
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Country | US
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Telephone | 313-903-3338
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Fax |
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Provider Business Mailing Address
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Address Line | 21103 FAIRVIEW DR
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City | DEARBORN HEIGHTS
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State | MI
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Zip | 48127-2686
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Country | US
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Telephone | 313-903-3338
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Fax |
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Authorized Official
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Title or Position | ADMIN
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Name | NERGIS JASSIM
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Credential | OTR
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Telephone | 313-903-3338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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