Provider Demographics
NPI:1053502468
Name:FANOUS, EBRAM M (PT)
Entity type:Individual
Prefix:
First Name:EBRAM
Middle Name:M
Last Name:FANOUS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3381 HIDDEN OAKS LN
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-3256
Mailing Address - Country:US
Mailing Address - Phone:586-335-8182
Mailing Address - Fax:248-757-2330
Practice Address - Street 1:36430 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-2746
Practice Address - Country:US
Practice Address - Phone:586-335-8182
Practice Address - Fax:248-757-2330
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011728225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist