Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 011162 | NY |
NPI | 1275003659 |
---|---|
Provider Name | Dr. Kimberly Sue Walitzer |
First Address | Brockport, NY 14420-1118 |
Second Address | Brockport, NY 14420-1118 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2018 |
Last Update Date | 28/11/2018 |