Provider Demographics
NPI:1265094395
Name:ABU SUBAIH, KHOLOUD SUDQI
Entity type:Individual
Prefix:MS
First Name:KHOLOUD
Middle Name:SUDQI
Last Name:ABU SUBAIH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KHOLOUD
Other - Middle Name:
Other - Last Name:ABU SUBAIH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2651 SAULINO CT
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1556
Mailing Address - Country:US
Mailing Address - Phone:313-842-7071
Mailing Address - Fax:313-842-5150
Practice Address - Street 1:6451 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2212
Practice Address - Country:US
Practice Address - Phone:313-945-8138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017269101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1265094395Medicaid