Provider Demographics
NPI:1316488919
Name:RAZA, ALI (COTAL, LMT)
Entity type:Individual
Prefix:MR
First Name:ALI
Middle Name:
Last Name:RAZA
Suffix:
Gender:M
Credentials:COTAL, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17452 HANOVER AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2837
Mailing Address - Country:US
Mailing Address - Phone:810-231-9042
Mailing Address - Fax:810-231-9063
Practice Address - Street 1:10400 HAMBURG ROAD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:MI
Practice Address - Zip Code:48139-0205
Practice Address - Country:US
Practice Address - Phone:810-231-9042
Practice Address - Fax:810-231-9063
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008228224Z00000X
TX214471224Z00000X
MI7501000019225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist