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General NPI Number Information
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NPI Number | 1134569635
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Entity Type | Individual
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Provider Name | MELISSA MANDL-MASE PH.D.
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Gender | Female
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Dates
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Enumeration Date | 06/28/2013
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Last Update Date | 06/28/2013
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Provider Practice Location Address
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Address Line | 461 W HURON ST SUITE 100
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City | PONTIAC
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State | MI
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Zip | 48341-1601
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Country | US
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Telephone | 248-456-1991
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Fax |
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Provider Business Mailing Address
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Address Line | 1527 MAYFIELD DR.
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City | ROYAL OAK
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State | MI
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Zip | 48067
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Country | US
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Telephone | 248-506-3036
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6301014863
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | CC7C3800099544
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License Number State | MI
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