Provider Demographics
NPI:1558441840
Name:MALL, HARRIET J (PHD)
Entity Type:Individual
Prefix:DR
First Name:HARRIET
Middle Name:J
Last Name:MALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
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Mailing Address - Street 1:30445 NORTHWESTERN HWY
Mailing Address - Street 2:STE 310
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3102
Mailing Address - Country:US
Mailing Address - Phone:248-538-5045
Mailing Address - Fax:248-538-1801
Practice Address - Street 1:30445 NORTHWESTERN HWY
Practice Address - Street 2:SUITE #240
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3158
Practice Address - Country:US
Practice Address - Phone:248-538-5045
Practice Address - Fax:248-538-1801
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI6401005154101YP2500X
MI6301008104103G00000X, 103T00000X, 103TA0700X, 103TF0000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11643507OtherCAQH
MIP39730001Medicare ID - Type Unspecified