Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 0813000927 | VA |
NPI | 1023513108 |
---|---|
Provider Name | Breonna Lashae Davis |
First Address | Norfolk, VA 23510-2723 |
Second Address | Norfolk, VA 23510-2723 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2018 |
Last Update Date | 29/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
31609 | (05) | VA |