Provider Demographics
NPI:1942704663
Name:CHOUDHURY, TAZUL (OTR)
Entity Type:Individual
Prefix:MR
First Name:TAZUL
Middle Name:
Last Name:CHOUDHURY
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 1:49678 WHITEHALL
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-6327
Mailing Address - Country:US
Mailing Address - Phone:313-377-8549
Mailing Address - Fax:
Practice Address - Street 1:34643 KETSIN DR.
Practice Address - Street 2:THERAPY DEPT.
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310
Practice Address - Country:US
Practice Address - Phone:586-978-2280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007510225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist