Provider Demographics
NPI:1841501392
Name:ANDRIES, MITCHELL ADRIAN (MALLPC)
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:ADRIAN
Last Name:ANDRIES
Suffix:
Gender:M
Credentials:MALLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17421 TELEGRAPH
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-5910
Mailing Address - Country:US
Mailing Address - Phone:313-255-0900
Mailing Address - Fax:313-255-3465
Practice Address - Street 1:17421 TELEGRAPH
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-5910
Practice Address - Country:US
Practice Address - Phone:313-255-0900
Practice Address - Fax:313-255-3465
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013921101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI213119549Medicaid