Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 1269141 | AZ |
NPI | 1023234408 |
---|---|
Provider Name | Martin Loftus |
First Address | Apache Junction, AZ 85220 |
Second Address | Apache Junction, AZ 85220 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/04/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
638223 | AHCCCS (01) | AZ |