Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC2200X | Clinical Child & Adolescent Psychologist | PS01443 | RI |
NPI | 1093121394 |
---|---|
Provider Name | Michael Walther |
First Address | Providence, RI 02903-4141 |
Second Address | Providence, RI 02903-4141 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2014 |
Last Update Date | 08/07/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PS01443 | PROFESSIONAL LICENSE (01) | RI |