Provider Demographics
NPI:1639632474
Name:BOUSAMRA, LEAH (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:BOUSAMRA
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4281
Mailing Address - Country:US
Mailing Address - Phone:734-645-9157
Mailing Address - Fax:
Practice Address - Street 1:46200 PORT ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6048
Practice Address - Country:US
Practice Address - Phone:734-454-0866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst