Provider Demographics
NPI:1659070837
Name:KAILANE, WALID
Entity Type:Individual
Prefix:
First Name:WALID
Middle Name:
Last Name:KAILANE
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 1:25614 FORD RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3024
Mailing Address - Country:US
Mailing Address - Phone:313-791-8000
Mailing Address - Fax:
Practice Address - Street 1:25614 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3024
Practice Address - Country:US
Practice Address - Phone:313-791-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6351001260102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08907974801Medicaid