Provider Demographics
NPI:1033943469
Name:MAHAMAT, ALI A (MASTER OF PSYCHOLOGY)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:A
Last Name:MAHAMAT
Suffix:
Gender:M
Credentials:MASTER OF PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 RERICK ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-2029
Mailing Address - Country:US
Mailing Address - Phone:574-300-4333
Mailing Address - Fax:
Practice Address - Street 1:236 SIMPSON AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-4666
Practice Address - Country:US
Practice Address - Phone:574-293-3786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TE1100X
AN103TH0100X
NA103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service