Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician |
NPI | 1003422759 |
---|---|
Provider Name | Matthew Prosch |
First Address | La Grange Park, IL 60526-1870 |
Second Address | Vestavia, AL 35216-3797 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/09/2020 |
Last Update Date | 18/09/2020 |