Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | 6301011054 | MI |
NPI | 1043423890 |
---|---|
Provider Name | Mr. Thomas Richard Stewart |
First Address | Grand Rapids, MI 49504-3757 |
Second Address | Ada, MI 49301-8455 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2007 |
Last Update Date | 08/07/2007 |