Provider Demographics
NPI:1043972532
Name:HARP, MANDA A (TLLP)
Entity Type:Individual
Prefix:
First Name:MANDA
Middle Name:A
Last Name:HARP
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25366 CLAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3802
Mailing Address - Country:US
Mailing Address - Phone:313-258-7558
Mailing Address - Fax:
Practice Address - Street 1:17282 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3151
Practice Address - Country:US
Practice Address - Phone:313-258-7558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009430103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical