Provider Demographics
NPI:1184822769
Name:MENTAL HEALTH CLINIC
Entity Type:Organization
Organization Name:MENTAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVINDER
Authorized Official - Middle Name:P
Authorized Official - Last Name:MEDIRATTA
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:269-342-0606
Mailing Address - Street 1:1514 W MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1296
Mailing Address - Country:US
Mailing Address - Phone:269-342-0606
Mailing Address - Fax:269-342-0919
Practice Address - Street 1:1514 W MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1296
Practice Address - Country:US
Practice Address - Phone:269-342-0606
Practice Address - Fax:269-342-0919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009051101YM0800X
MIRM43010525122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICL4211Medicare PIN
MI0N89270Medicare ID - Type Unspecified
MIE49675Medicare UPIN