Provider Demographics
NPI:1841775244
Name:KHAN, SHAHID (OTR)
Entity Type:Individual
Prefix:
First Name:SHAHID
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22109 NIXON AVE
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48193-8233
Mailing Address - Country:US
Mailing Address - Phone:734-846-6003
Mailing Address - Fax:
Practice Address - Street 1:481 VILLAGE GREEN LN
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3367
Practice Address - Country:US
Practice Address - Phone:734-242-6282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
MI5201004246225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist