Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) |
NPI | 1346804390 |
---|---|
Provider Name | Kimberly Dick |
First Address | Indianapolis, IN 46268-6135 |
Second Address | Fort Wayne, IN 46815-6917 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2019 |
Last Update Date | 25/04/2019 |