Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PSY001999 | GA |
Y | 103TC0700X | Clinical Psychologist | PSY001999 | GA |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | PSY001999 | GA |
NPI | 1063420875 |
---|---|
Provider Name | Dr. Mark J. Prigatano |
First Address | Macon, GA 31204-2871 |
Second Address | Macon, GA 31204-2871 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/08/2006 |
Last Update Date | 21/03/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000730254C | (05) | GA |