Provider Demographics
NPI:1124661459
Name:ISSAWI, SAFAA (MA)
Entity type:Individual
Prefix:
First Name:SAFAA
Middle Name:
Last Name:ISSAWI
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27324 STRAWBERRY LN APT 203
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5049
Mailing Address - Country:US
Mailing Address - Phone:810-624-4204
Mailing Address - Fax:
Practice Address - Street 1:1025 E FOREST AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1024
Practice Address - Country:US
Practice Address - Phone:313-833-2692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018025103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical