Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician |
NPI | 1003389826 |
---|---|
Provider Name | Katina Blaine |
First Address | Modesto, CA 95355-1582 |
Second Address | Riverbank, CA 95367 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2019 |
Last Update Date | 20/02/2019 |