Provider Demographics
NPI:1033589320
Name:BYAIS, IDELLMAR (BSW)
Entity Type:Individual
Prefix:
First Name:IDELLMAR
Middle Name:
Last Name:BYAIS
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:IDELLMAR
Other - Middle Name:
Other - Last Name:BYAIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAC-1
Mailing Address - Street 1:15941 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-4123
Mailing Address - Country:US
Mailing Address - Phone:313-345-4310
Mailing Address - Fax:313-345-4315
Practice Address - Street 1:15941 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-4123
Practice Address - Country:US
Practice Address - Phone:313-345-4310
Practice Address - Fax:313-345-4315
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-02103101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)