Provider Demographics
NPI:1730570078
Name:KHALIL, LAURA MARIE (CAD)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:KHALIL
Suffix:
Gender:F
Credentials:CAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22790 KELLY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2019
Mailing Address - Country:US
Mailing Address - Phone:586-771-7600
Mailing Address - Fax:586-771-7617
Practice Address - Street 1:22790 KELLY RD
Practice Address - Street 2:SUITE A
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2019
Practice Address - Country:US
Practice Address - Phone:586-771-7600
Practice Address - Fax:586-771-7617
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2016-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA0500442261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI204239789OtherEIN