Individual
GREGORY POULIOT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHD
Contact information
Practice address
714 N MICHIGAN ST, SOUTH BEND, IN 46601-1035
(574) 647-7477
(574) 647-3655
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
(574) 237-6069
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
20042945A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201392530
—
IN
Enumeration date
08/27/2014
Last updated
03/31/2021
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