Provider Demographics
NPI:1215308101
Name:MANSOUR, YASSER
Entity type:Individual
Prefix:
First Name:YASSER
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 REPUBLIC DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-3658
Mailing Address - Country:US
Mailing Address - Phone:313-207-4645
Mailing Address - Fax:313-436-5188
Practice Address - Street 1:1721 MORNINGSIDE WAY
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-1244
Practice Address - Country:US
Practice Address - Phone:313-207-4645
Practice Address - Fax:877-811-8112
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-17
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI900747294171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator