Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 106S00000X | Behavior Technician | ||
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1003406810 |
---|---|
Provider Name | Kenny Junior Rodriguez Trujillo |
First Address | Greenbrae, CA 94904 |
Second Address | Greenbrae, CA 94904 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2021 |
Last Update Date | 20/07/2021 |