Provider Demographics
NPI:1649739343
Name:HANTALASEVIC, ALMEDINA
Entity type:Individual
Prefix:MS
First Name:ALMEDINA
Middle Name:
Last Name:HANTALASEVIC
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 1:9420 LATHAM
Mailing Address - Street 2:9420 LATHAM O
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212
Mailing Address - Country:US
Mailing Address - Phone:810-824-2850
Mailing Address - Fax:
Practice Address - Street 1:9420 LATHAM ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3413
Practice Address - Country:US
Practice Address - Phone:810-824-2850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI01101995OtherMOLINA HEALTHCARE
MI051981Medicaid