Healthcare Provider Details

I. General information

NPI: 1417386608
Provider Name (Legal Business Name): SARAH BOUALI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42804 GARFIELD RD
CLINTON TOWNSHIP MI
48038-1656
US

IV. Provider business mailing address

42804 GARFIELD RD
CLINTON TOWNSHIP MI
48038-1656
US

V. Phone/Fax

Practice location:
  • Phone: 586-323-2957
  • Fax: 586-323-0022
Mailing address:
  • Phone: 586-323-2957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number5201009102
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: