Provider Demographics
NPI:1376189761
Name:MAZLOUM, ISRAA HASSAN (MOTRL)
Entity Type:Individual
Prefix:MS
First Name:ISRAA
Middle Name:HASSAN
Last Name:MAZLOUM
Suffix:
Gender:F
Credentials:MOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26261 VAN BUREN RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-1111
Mailing Address - Country:US
Mailing Address - Phone:313-585-0864
Mailing Address - Fax:
Practice Address - Street 1:28050 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5919
Practice Address - Country:US
Practice Address - Phone:947-521-8604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010251225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist