Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 17175 | WI |
NPI | 1003220450 |
---|---|
Provider Name | Duarte Cespedes Perez |
First Address | Black River Falls, WI 54615-9998 |
Second Address | Black River Falls, WI 54615-9998 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2014 |
Last Update Date | 13/06/2014 |