Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 291 | WY |
N | 103T00000X | Psychologist | 291 | WY |
N | 103G00000X | Clinical Psychologist | 291 | WY |
N | 103TC0700X | Clinical Psychologist | 291 | WY |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | 291 | WY |
N | 103TF0000X | Family Psychologist | 291 | WY |
NPI | 1003030511 |
---|---|
Provider Name | Dr. Vivian Gay Deitrich-Maclean |
First Address | Laramie, WY 82070-3729 |
Second Address | Laramie, WY 82070-3729 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/04/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
119587500 | (05) | WY |