Provider Demographics
NPI:1871894675
Name:BAZZI, FATEN Y (MS, LLP)
Entity type:Individual
Prefix:
First Name:FATEN
Middle Name:Y
Last Name:BAZZI
Suffix:
Gender:F
Credentials:MS, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 EASTHAM RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1049
Mailing Address - Country:US
Mailing Address - Phone:313-505-0594
Mailing Address - Fax:
Practice Address - Street 1:363 W BIG BEAVER RD STE 315
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-5242
Practice Address - Country:US
Practice Address - Phone:248-354-8460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-10
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014548103TC0700X
MI6361007094103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3434247Medicaid