Provider Demographics
NPI:1750809190
Name:KHATIB, SAMAH (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:SAMAH
Middle Name:
Last Name:KHATIB
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12279
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-2279
Mailing Address - Country:US
Mailing Address - Phone:571-245-4777
Mailing Address - Fax:517-698-8223
Practice Address - Street 1:2021 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2926
Practice Address - Country:US
Practice Address - Phone:517-245-4778
Practice Address - Fax:517-698-8223
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI7401001244103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician