Provider Demographics
NPI:1861164345
Name:HASAN, KHAIRUN ROSHNEE
Entity type:Individual
Prefix:
First Name:KHAIRUN
Middle Name:ROSHNEE
Last Name:HASAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 ELDON ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6133
Mailing Address - Country:US
Mailing Address - Phone:616-309-6931
Mailing Address - Fax:
Practice Address - Street 1:1115 BALL AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5904
Practice Address - Country:US
Practice Address - Phone:616-309-6931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIH250468744866101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health