Provider Demographics
NPI:1417755158
Name:KOUBAYSSI, HASSAN
Entity type:Individual
Prefix:MR
First Name:HASSAN
Middle Name:
Last Name:KOUBAYSSI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 BAY 26TH ST APT 3G
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-4996
Mailing Address - Country:US
Mailing Address - Phone:929-592-6330
Mailing Address - Fax:
Practice Address - Street 1:4520 FIRESTONE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4602
Practice Address - Country:US
Practice Address - Phone:313-470-1860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362010097103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical