Provider Demographics
NPI:1376812867
Name:MANSOUR, KRISTINA
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30200 TELEGRAPH RD STE 207
Mailing Address - Street 2:
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5711
Mailing Address - Country:US
Mailing Address - Phone:248-712-1129
Mailing Address - Fax:
Practice Address - Street 1:28175 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2903
Practice Address - Country:US
Practice Address - Phone:734-265-0841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012155101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3434247Medicaid