Provider Demographics
NPI:1114705449
Name:SAFAH, EBRAHIM
Entity Type:Individual
Prefix:
First Name:EBRAHIM
Middle Name:
Last Name:SAFAH
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 1:17539 MELROSE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4259
Mailing Address - Country:US
Mailing Address - Phone:313-912-9126
Mailing Address - Fax:
Practice Address - Street 1:44450 PINETREE DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-3869
Practice Address - Country:US
Practice Address - Phone:089-773-8734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009802103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical