Basic Information
| Provider Information | |||||||||
| NPI: | 1811311301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINGLEDOFF | ||||||||
| FirstName: | LUKISHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13101 ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 21751 ECORSE RD | ||||||||
| Address2: | |||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481801846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134064493 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2014 | ||||||||
| LastUpdateDate: | 08/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 101YP2500X | 6401014065 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.