Healthcare Provider Details

I. General information

NPI: 1902021405
Provider Name (Legal Business Name): PRATHIMA MISTRY PH.D. LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 W BIG BEAVER RD SUITE 520
TROY MI
48084-3407
US

IV. Provider business mailing address

11480 E 13 MILE RD
WARREN MI
48093-2566
US

V. Phone/Fax

Practice location:
  • Phone: 248-646-6659
  • Fax:
Mailing address:
  • Phone: 586-216-9253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number22251
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301012647
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: