=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922202159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE M MEHTA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 04/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | WHITE EARTH MENTAL HEALTH CLINIC 40520 COUNTY HIGHWAY 34
-----------------------------------------------------
City | OGEMA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-983-6325
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6682
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55903-6682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-401-2187
-----------------------------------------------------
Fax | 832-324-6927
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 63813
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------