Provider Demographics
NPI:1518433895
Name:MOSA-BASHA, KEITH (LCSW)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:MOSA-BASHA
Suffix:
Gender:M
Credentials:LCSW
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 250304
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48325-0304
Mailing Address - Country:US
Mailing Address - Phone:248-970-2163
Mailing Address - Fax:855-639-6781
Practice Address - Street 1:30701 WOODWARD AVE
Practice Address - Street 2:
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:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011032031041C0700X
MI68011166901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical