Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | 00014088 | MI |
Y | 101YP2500X | Professional Counselor | 6401005523 | MI |
N | 101YS0200X | School Counselor | MI-SC0000000749838 | MI |
NPI | 1184029340 |
---|---|
Provider Name | John Smith |
First Address | Waterford, MI 48328-3618 |
Second Address | Redford, MI 48239-1260 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/10/2014 |
Last Update Date | 20/09/2018 |