Provider Demographics
NPI:1710012372
Name:MIND & MOOD CLINIC, PLLC
Entity Type:Organization
Organization Name:MIND & MOOD CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIKSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-851-1800
Mailing Address - Street 1:7071 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3669
Mailing Address - Country:US
Mailing Address - Phone:248-851-1800
Mailing Address - Fax:248-851-8201
Practice Address - Street 1:7071 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 225
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3669
Practice Address - Country:US
Practice Address - Phone:248-851-1800
Practice Address - Fax:248-851-8201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherPPOM IDENTIFIER
MI0P07350Medicare ID - Type UnspecifiedPHD GROUP
MI=========OtherPPOM IDENTIFIER
MI0P07340Medicare ID - Type UnspecifiedMD GROUP