Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TB0200X | Cognitive & Behavioral Psychologist | ||
Y | 103G00000X | Clinical Psychologist | 6301006431 | MI |
Y | 103TC0700X | Clinical Psychologist | 6301006431 | MI |
N | 103TH0100X | Health Service | ||
N | 103TP2701X | Group Psychotherapist | 6301006431 | MI |
N | 103TR0400X | Rehabilitation Psychologist |
NPI | 1386656023 |
---|---|
Provider Name | Terry L Braciszewski |
First Address | Howell, MI 48843-2221 |
Second Address | Dexter, MI 48130-1344 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2006 |
Last Update Date | 26/08/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
610093200 | ACS/OWCP (01) | OH |
680H146930 | BCBSM (01) | MI |
S01175 | (02) |