Provider Demographics
NPI:1649642877
Name:MUKHTAR, MARIAM
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:MUKHTAR
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 1:1575 CRANWOOD CT
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2303
Mailing Address - Country:US
Mailing Address - Phone:517-366-0977
Mailing Address - Fax:
Practice Address - Street 1:1701 LAKE LANSING RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3798
Practice Address - Country:US
Practice Address - Phone:810-494-7180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2024-10-22
Deactivation Date:2020-05-20
Deactivation Code:
Reactivation Date:2024-10-22
Provider Licenses
StateLicense IDTaxonomies
MI6301017146103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling