Provider Demographics
NPI:1528685732
Name:KHAMUSH, BASAK AMELIA (PHD)
Entity type:Individual
Prefix:
First Name:BASAK
Middle Name:AMELIA
Last Name:KHAMUSH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1298 STARBOARD DR
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3482
Mailing Address - Country:US
Mailing Address - Phone:216-926-0415
Mailing Address - Fax:
Practice Address - Street 1:463 E CIRCLE DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7500
Practice Address - Country:US
Practice Address - Phone:517-355-8270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling