Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 6301009981 | MI |
N | 103T00000X | Psychologist | 6301009981 | MI |
Y | 103G00000X | Clinical Psychologist | 6301009981 | MI |
Y | 103TC0700X | Clinical Psychologist | 6301009981 | MI |
NPI | 1003988528 |
---|---|
Provider Name | Mary E Theisen-Goodvich |
First Address | Ann Arbor, MI 48108-1633 |
Second Address | Ann Arbor, MI 48108-3439 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/11/2006 |
Last Update Date | 28/02/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P42951 | (02) | MI |