Provider Demographics
NPI:1396001939
Name:ABOUKHATWA, IMAN A (PT)
Entity Type:Individual
Prefix:MRS
First Name:IMAN
Middle Name:A
Last Name:ABOUKHATWA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:IMAN
Other - Middle Name:A
Other - Last Name:ABOUKHATWA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:49255 DOMINION CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-5807
Mailing Address - Country:US
Mailing Address - Phone:734-844-2336
Mailing Address - Fax:
Practice Address - Street 1:38777 6 MILE RD SUITE 209
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:888-414-7056
Practice Address - Fax:877-414-9925
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012858225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist