Provider Demographics
NPI:1699362517
Name:KHALIQUE, TAMANNA
Entity Type:Individual
Prefix:
First Name:TAMANNA
Middle Name:
Last Name:KHALIQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42102 RIDGE RD W
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2673
Mailing Address - Country:US
Mailing Address - Phone:586-322-3403
Mailing Address - Fax:
Practice Address - Street 1:42102 RIDGE RD W
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2673
Practice Address - Country:US
Practice Address - Phone:313-212-0189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-26
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010892225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201010892OtherLICENSE NUMBER