Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TB0200X | Cognitive & Behavioral Psychologist | 734 | NE |
NPI | 1023139227 |
---|---|
Provider Name | Daniel Lee Fudge |
First Address | Hamden, CT 06518-3508 |
Second Address | Lincoln, NE 68516-1276 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2007 |
Last Update Date | 08/07/2015 |