Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst |
NPI | 1003379447 |
---|---|
Provider Name | Makayla Sample |
First Address | Lacey, WA 98516-7162 |
Second Address | Lacey, WA 98516-7162 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2019 |
Last Update Date | 11/04/2019 |