Healthcare Provider Details

I. General information

NPI: 1811311301
Provider Name (Legal Business Name): LUKISHA MINGLEDOFF LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21751 ECORSE RD
TAYLOR MI
48180-1846
US

IV. Provider business mailing address

13101 ALLEN RD
SOUTHGATE MI
48195-2216
US

V. Phone/Fax

Practice location:
  • Phone: 313-406-4493
  • Fax:
Mailing address:
  • Phone: 734-785-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014065
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: