Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician |
NPI | 1003401555 |
---|---|
Provider Name | Gregory Noah Theodore |
First Address | San Francisco, CA 94139-9318 |
Second Address | San Jose, CA 95126-1453 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/03/2021 |
Last Update Date | 06/03/2021 |