Provider Demographics
NPI:1861866303
Name:KHALIQ, FAZAL (PT)
Entity Type:Individual
Prefix:
First Name:FAZAL
Middle Name:
Last Name:KHALIQ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26017 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4703
Mailing Address - Country:US
Mailing Address - Phone:248-291-5301
Mailing Address - Fax:
Practice Address - Street 1:26017 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4703
Practice Address - Country:US
Practice Address - Phone:248-291-5301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017486225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist