Provider Demographics
NPI:1619082617
Name:GHANEM, MISSID GEORGE (PSYD)
Entity Type:Individual
Prefix:
First Name:MISSID
Middle Name:GEORGE
Last Name:GHANEM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26515 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-1966
Mailing Address - Country:US
Mailing Address - Phone:281-367-0328
Mailing Address - Fax:281-419-9753
Practice Address - Street 1:26515 OAKRIDGE DR
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:TX
Practice Address - Zip Code:77380
Practice Address - Country:US
Practice Address - Phone:281-367-0328
Practice Address - Fax:281-419-9753
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26864103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y917OtherMEDICARE GROUP P-TAN
TX097011302Medicaid
TX097011302Medicaid
TX00Y917OtherMEDICARE GROUP P-TAN