Provider Demographics
NPI:1700426699
Name:FAKHERDDINE, REEM BAHA (MA TLLP)
Entity Type:Individual
Prefix:MISS
First Name:REEM
Middle Name:BAHA
Last Name:FAKHERDDINE
Suffix:
Gender:F
Credentials:MA TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6434 KENDAL ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2149
Mailing Address - Country:US
Mailing Address - Phone:313-520-0055
Mailing Address - Fax:
Practice Address - Street 1:8623 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1137
Practice Address - Country:US
Practice Address - Phone:734-367-0469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018111103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical