Provider Demographics
NPI:1033499868
Name:FAKHERI, MENUCHA (SLP)
Entity type:Individual
Prefix:
First Name:MENUCHA
Middle Name:
Last Name:FAKHERI
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 CARLSON LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-1309
Mailing Address - Country:US
Mailing Address - Phone:410-887-0766
Mailing Address - Fax:
Practice Address - Street 1:8300 CARLSON LN STE 4
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-1309
Practice Address - Country:US
Practice Address - Phone:410-887-0766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06694235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist