Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | PY7470 | FL |
Y | 103T00000X | Psychologist | PY7470 | FL |
NPI | 1003939349 |
---|---|
Provider Name | Janeane Reagan |
First Address | Plant City, FL 33563-5403 |
Second Address | Lady Lake, FL 32159-4202 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2007 |
Last Update Date | 05/05/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PY7470 | MEDICAL LICENSE # (01) | FL |