Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | C-02456 | MI |
Y | 103G00000X | Clinical Psychologist | 6301005605 | MI |
Y | 103TC0700X | Clinical Psychologist | 6301005605 | MI |
NPI | 1548566029 |
---|---|
Provider Name | Martha Bridget Nacy |
First Address | Brighton, MI 48116-8506 |
Second Address | Brighton, MI 48116 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2011 |
Last Update Date | 11/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
13854015 | CAQH (01) | |
6301005605 | LLP (01) | MI |