Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003087453 |
---|---|
Provider Name | Justin Reid |
First Address | Berkeley, CA 94703-2309 |
Second Address | San Leandro, CA 94578-2102 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/03/2008 |
Last Update Date | 13/03/2008 |