Provider Demographics
NPI:1902021405
Name:MISTRY, PRATHIMA (PHD LLP)
Entity Type:Individual
Prefix:
First Name:PRATHIMA
Middle Name:
Last Name:MISTRY
Suffix:
Gender:F
Credentials:PHD LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11480 E 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2566
Mailing Address - Country:US
Mailing Address - Phone:586-216-9253
Mailing Address - Fax:
Practice Address - Street 1:2075 W BIG BEAVER RD
Practice Address - Street 2:SUITE 520
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3407
Practice Address - Country:US
Practice Address - Phone:248-646-6659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22251103T00000X
MI6301012647103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist