Provider Demographics
NPI:1003361007
Name:FARAJ, ANTWAN (DPT)
Entity Type:Individual
Prefix:
First Name:ANTWAN
Middle Name:
Last Name:FARAJ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:FARAJ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:344 E HARRY AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-2055
Mailing Address - Country:US
Mailing Address - Phone:586-871-4805
Mailing Address - Fax:
Practice Address - Street 1:668 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1962
Practice Address - Country:US
Practice Address - Phone:248-733-5052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist