Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health | 5201001977 | MI |
NPI | 1841594215 |
---|---|
Provider Name | Ms. Molly Buist |
First Address | Jenison, MI 49428-9352 |
Second Address | Jenison, MI 49428-9352 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/12/2010 |
Last Update Date | 29/12/2010 |