Provider Demographics
NPI:1578994190
Name:FARAJ, IBRAHEEM
Entity Type:Individual
Prefix:
First Name:IBRAHEEM
Middle Name:
Last Name:FARAJ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 LANSING RD N
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-2526
Mailing Address - Country:US
Mailing Address - Phone:518-248-4989
Mailing Address - Fax:518-630-5664
Practice Address - Street 1:25 LANSING RD N
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-2526
Practice Address - Country:US
Practice Address - Phone:518-248-4989
Practice Address - Fax:518-630-5664
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-07
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY036883OtherLICENSE