Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | LP 5514 | MN |
NPI | 1154678936 |
---|---|
Provider Name | Kabita Roy |
First Address | Center City, MN 55012-9640 |
Second Address | Center City, MN 55012-9640 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2012 |
Last Update Date | 10/08/2012 |