Provider Demographics
NPI:1710059076
Name:MANDICH, CHRISTINE ROSE (MALLP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ROSE
Last Name:MANDICH
Suffix:
Gender:F
Credentials:MALLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20864 PARKCREST DR
Mailing Address - Street 2:
Mailing Address - City:HARPER WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48225-1708
Mailing Address - Country:US
Mailing Address - Phone:586-263-2760
Mailing Address - Fax:586-263-2762
Practice Address - Street 1:43411 GARFIELD RD STE A
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1152
Practice Address - Country:US
Practice Address - Phone:586-263-2760
Practice Address - Fax:586-263-2762
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009728103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist