Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 0803000235 | VA |
NPI | 1073027074 |
---|---|
Provider Name | Kristen Micheal |
First Address | Roanoke, VA 24019-2403 |
Second Address | Roanoke, VA 24019-2403 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2017 |
Last Update Date | 29/11/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0803000235 | (05) | VA |