Basic Information
| Provider Information | |||||||||
| NPI: | 1124118070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAHRI | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | HAILO | ||||||||
| OtherFirstName: | LINDA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2703 RAVINEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COMMERCE TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483825400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482526148 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1800 N MILFORD RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MILFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483811047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486846400 | ||||||||
| FaxNumber: | 2486845973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301010129 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.