Provider Demographics
NPI:1518477165
Name:RESTUM, SHADI
Entity Type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:RESTUM
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 1:6345 OAKMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2311
Mailing Address - Country:US
Mailing Address - Phone:313-515-1077
Mailing Address - Fax:
Practice Address - Street 1:835 MASON ST STE A-240
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2231
Practice Address - Country:US
Practice Address - Phone:313-515-1077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2021-07-08
Deactivation Date:2021-04-04
Deactivation Code:
Reactivation Date:2021-05-06
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician