Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | PSYPST00213906 | KY |
NPI | 1104207042 |
---|---|
Provider Name | Jay Deiters |
First Address | Lexington, KY 40502-2235 |
Second Address | Lexington, KY 40502-2235 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2015 |
Last Update Date | 16/06/2015 |