Healthcare Provider Details

I. General information

NPI: 1225392350
Provider Name (Legal Business Name): MONGIA MISOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34290 FORD RD
WESTLAND MI
48185-3051
US

IV. Provider business mailing address

34290 FORD RD
WESTLAND MI
48185-3051
US

V. Phone/Fax

Practice location:
  • Phone: 734-412-8800
  • Fax:
Mailing address:
  • Phone: 734-412-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704367989
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: