Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician |
NPI | 1003410994 |
---|---|
Provider Name | Kennedy Massa |
First Address | Colorado Springs, CO 80906-4651 |
Second Address | Colorado Springs, CO 80906-4651 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/11/2020 |
Last Update Date | 23/11/2020 |