MEDICARE: CHRISTINE ROSE MANDICH MALLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6301009728	MI

General Provider Information

NPI Number	:	1710059076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE ROSE MANDICH MALLP

Provider Business Mailing Address
First Line	:	20864 PARKCREST DR
Second Line	:
City	:	HARPER WOODS
State	:	MI
Zip	:	48225-1708
Country	:	US
Telephone Number	:	586-263-2760
Fax Number	:	586-263-2762

Provider Business Practice Location Address
First Line	:	43411 GARFIELD RD STE A
Second Line	:
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48038-1152
Country	:	US
Telephone Number	:	586-263-2760
Fax Number	:	586-263-2762

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	01/21/2021

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