Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst |
NPI | 1003454547 |
---|---|
Provider Name | Blaike Johnson |
First Address | Dallas, TX 75248-1961 |
Second Address | Murphy, TX 75094-3748 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/12/2019 |
Last Update Date | 16/12/2019 |