Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor | P79437 | NY |
NPI | 1114268836 |
---|---|
Provider Name | Johny Dominic |
First Address | New York, NY 10017-4007 |
Second Address | New York, NY 10107-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/03/2013 |
Last Update Date | 05/03/2013 |