Healthcare Provider Details

I. General information

NPI: 1700705936
Provider Name (Legal Business Name): BAHIJA KHADDOUR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 AUDUBON TRL
LUTZ FL
33549-9513
US

IV. Provider business mailing address

1813 AUDUBON TRL
LUTZ FL
33549-9513
US

V. Phone/Fax

Practice location:
  • Phone: 720-717-3580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberK621-345-14-700-0
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: