Healthcare Provider Details

I. General information

NPI: 1053848713
Provider Name (Legal Business Name): MANDY GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43825 MICHIGAN AVE
CANTON MI
48188-2551
US

IV. Provider business mailing address

37450 SCHOOLCRAFT RD STE 110
LIVONIA MI
48150-1000
US

V. Phone/Fax

Practice location:
  • Phone: 734-397-3088
  • Fax:
Mailing address:
  • Phone: 734-458-4601
  • Fax: 734-793-5380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: