Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | ||
Y | 103T00000X | Psychologist |
NPI | 1003199449 |
---|---|
Provider Name | Amy Willis |
First Address | Belleville, MI 48111-3441 |
Second Address | Auburn Hills, MI 48326-1955 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2011 |
Last Update Date | 08/03/2017 |