Healthcare Provider Details

I. General information

NPI: 1649642877
Provider Name (Legal Business Name): MARIAM MUKHTAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 10/22/2024
Certification Date: 05/20/2020
Deactivation Date: 05/20/2020
Reactivation Date: 10/22/2024

III. Provider practice location address

1701 LAKE LANSING RD
LANSING MI
48912-3798
US

IV. Provider business mailing address

1575 CRANWOOD CT
OKEMOS MI
48864-2303
US

V. Phone/Fax

Practice location:
  • Phone: 810-494-7180
  • Fax:
Mailing address:
  • Phone: 517-366-0977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301017146
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: