Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YP1600X | Pastoral Counselor | CO |
NPI | 1073729828 |
---|---|
Provider Name | Dr. Ralph S. Datema |
First Address | Arvada, CO 80004-3822 |
Second Address | Burlington, CO 80807-1645 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2007 |
Last Update Date | 15/08/2011 |