MEDICARE: AMYNA FTOUNI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301016427	MI
2	103TH0100X	Health Service Psychologist	6352000039	MI
3	103TC0700X	Clinical Psychologist	6352000039	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P261145	OTHER	MI	BCBS PROVIDER ID

General Provider Information

NPI Number	:	1669843850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMYNA FTOUNI

Provider Business Mailing Address
First Line	:	5643 DACOSTA ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-2415
Country	:	US
Telephone Number	:	313-909-4099
Fax Number	:

Provider Business Practice Location Address
First Line	:	135 N OLD WOODWARD AVE STE 200
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-3341
Country	:	US
Telephone Number	:	313-444-9887
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2015
Last Update Date	:	04/18/2025

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