Provider Demographics
NPI:1982134664
Name:AL DARWEESH, HAIDER HASSAN
Entity type:Individual
Prefix:
First Name:HAIDER
Middle Name:HASSAN
Last Name:AL DARWEESH
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 1:23400 MICHIGAN AVE STE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3258 BROAD ST STE 2
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-1142
Practice Address - Country:US
Practice Address - Phone:734-664-2528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI6362009232103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty