Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst | CG60396523 | WA |
NPI | 1003240177 |
---|---|
Provider Name | Michael Connolly |
First Address | Federal Way, WA 98063-3841 |
Second Address | Tacoma, WA 98422-1015 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/08/2013 |
Last Update Date | 26/08/2013 |