Provider Demographics
NPI:1891092268
Name:BASYOUNI, EITEDAL (PHD)
Entity Type:Individual
Prefix:
First Name:EITEDAL
Middle Name:
Last Name:BASYOUNI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30701 WOODWARD AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0987
Mailing Address - Country:US
Mailing Address - Phone:248-288-9333
Mailing Address - Fax:248-288-1362
Practice Address - Street 1:30701 WOODWARD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0987
Practice Address - Country:US
Practice Address - Phone:248-288-9333
Practice Address - Fax:248-288-1362
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401002100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health