Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 8097827-2501 | UT |
Y | 103T00000X | Psychologist | 8097827-2501 | UT |
NPI | 1013342690 |
---|---|
Provider Name | Michael M. Haderlie |
First Address | Pleasant Grove, UT 84062 |
Second Address | Pleasant Grove, UT 84062 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2013 |
Last Update Date | 13/09/2013 |