Provider Demographics
NPI:1497328389
Name:REDGATE, MIKALA
Entity Type:Individual
Prefix:
First Name:MIKALA
Middle Name:
Last Name:REDGATE
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 1:70 W ALEXANDRINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2051
Mailing Address - Country:US
Mailing Address - Phone:978-968-7385
Mailing Address - Fax:
Practice Address - Street 1:79 W ALEXANDRINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2015
Practice Address - Country:US
Practice Address - Phone:979-831-5535
Practice Address - Fax:313-831-2608
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator