Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | 6301009928 | MI |
NPI | 1104913177 |
---|---|
Provider Name | Mr. Thomas Edward Haefner |
First Address | Livonia, MI 48154-3736 |
Second Address | Wayne, MI 48184-2405 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/10/2006 |
Last Update Date | 08/07/2007 |