Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | PSY15513 | CA |
Y | 103T00000X | Psychologist | PSY15513 | CA |
N | 103TR0400X | Rehabilitation Psychologist | PSY15513 | CA |
NPI | 1003911124 |
---|---|
Provider Name | Marie Roman-Clifton |
First Address | San Jose, CA 95128-2604 |
Second Address | San Jose, CA 95128-2604 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2006 |
Last Update Date | 12/09/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Q32748 | (02) | CA |