Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist |
NPI | 1124454509 |
---|---|
Provider Name | Carlos Williams |
First Address | Boise, ID 83705-2877 |
Second Address | Boise, ID 83705-2877 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/09/2013 |
Last Update Date | 10/06/2015 |