Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106E00000X | Assistant Behavior Analyst |
NPI | 1073087938 |
---|---|
Provider Name | John Park |
First Address | San Diego, CA 92123-1324 |
Second Address | San Diego, CA 92123-1324 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/01/2019 |
Last Update Date | 08/02/2021 |