Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 6401012805 | MI |
NPI | 1003173113 |
---|---|
Provider Name | Mr. Ronald Evan Hormel |
First Address | Troy, MI 48084 |
Second Address | Troy, MI 48084 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/04/2012 |
Last Update Date | 24/07/2013 |