Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC2200X | Clinical Child & Adolescent Psychologist | 6301014003 | MI |
NPI | 1053603225 |
---|---|
Provider Name | Miss Amy Kathleen Pruneau |
First Address | Walled Lake, MI 48390-3661 |
Second Address | Walled Lake, MI 48390-3661 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/05/2011 |
Last Update Date | 06/05/2011 |