Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003228362 |
---|---|
Provider Name | Marcus Johnson SR. |
First Address | Las Vegas, NV 89120-3295 |
Second Address | Las Vegas, NV 89120-3295 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/05/2014 |
Last Update Date | 21/05/2014 |