Healthcare Provider Details

I. General information

NPI: 1457789109
Provider Name (Legal Business Name): MUNA MASHRAH TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 W 7 MILE RD
DETROIT MI
48203-1967
US

IV. Provider business mailing address

4725 ORCHARD AVE
DEARBORN MI
48126-4600
US

V. Phone/Fax

Practice location:
  • Phone: 313-893-6172
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015733
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: