Provider Demographics
NPI:1114493434
Name:CHOUDHURY, MUNTASIR (OTR/L)
Entity Type:Individual
Prefix:
First Name:MUNTASIR
Middle Name:
Last Name:CHOUDHURY
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 TROWBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3284
Mailing Address - Country:US
Mailing Address - Phone:313-879-5737
Mailing Address - Fax:
Practice Address - Street 1:100 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-1926
Practice Address - Country:US
Practice Address - Phone:702-332-6864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010328225X00000X
NVOT-2130225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist