Basic Information
| Provider Information | |||||||||
| NPI: | 1700426699 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAKHERDDINE | ||||||||
| FirstName: | REEM | ||||||||
| MiddleName: | BAHA | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA TLLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6434 KENDAL ST | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481262149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135200055 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8623 N WAYNE RD | ||||||||
| Address2: | |||||||||
| City: | WESTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481851137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343670469 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2020 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301018111 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.