Provider Demographics
NPI:1821595711
Name:FARHAT-HENDRICKS, KAREN AMAL (OT/L)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:AMAL
Last Name:FARHAT-HENDRICKS
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3683 MAPLEBROOK DR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-2709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3683 MAPLEBROOK DR NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-2709
Practice Address - Country:US
Practice Address - Phone:616-204-5293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006651225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201006651Medicaid