Provider Demographics
NPI:1609393735
Name:MEHTA, MANSI SHARADKUMAR
Entity type:Individual
Prefix:
First Name:MANSI
Middle Name:SHARADKUMAR
Last Name:MEHTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37875 W 12 MILE RD STE 208
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-3053
Mailing Address - Country:US
Mailing Address - Phone:734-251-2662
Mailing Address - Fax:832-324-6751
Practice Address - Street 1:705 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2089
Practice Address - Country:US
Practice Address - Phone:734-454-3560
Practice Address - Fax:832-324-6751
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-29
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.021452363LF0000X, 363LP0808X
MI4704327956363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily