Provider Demographics
NPI:1194243493
Name:ALISSAWI, INTITHAR
Entity type:Individual
Prefix:
First Name:INTITHAR
Middle Name:
Last Name:ALISSAWI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41774 W VILLAGE GREEN BLVD APT 206
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3879
Mailing Address - Country:US
Mailing Address - Phone:313-759-1507
Mailing Address - Fax:
Practice Address - Street 1:23527 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48128-1260
Practice Address - Country:US
Practice Address - Phone:313-633-0364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 374700000X
MI7401001365103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374700000XNursing Service Related ProvidersTechnician