Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | 5103 | ND |
NPI | 1003370149 |
---|---|
Provider Name | Becka Anne Koll |
First Address | Mandan, ND 58554-3124 |
Second Address | Mandan, ND 58554-3124 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2019 |
Last Update Date | 23/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
104100000X | (05) | ND |