Provider Demographics
NPI:1568752657
Name:IBRAHEEM, REMI M (LICAC)
Entity Type:Individual
Prefix:MISS
First Name:REMI
Middle Name:M
Last Name:IBRAHEEM
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CENTENNIAL AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-2502
Mailing Address - Country:US
Mailing Address - Phone:978-290-6017
Mailing Address - Fax:
Practice Address - Street 1:114 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-5706
Practice Address - Country:US
Practice Address - Phone:978-290-6017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226468171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist