Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician | 106S00000X | CA |
NPI | 1003378373 |
---|---|
Provider Name | Mina Grace |
First Address | Canyon Country, CA 91387-3188 |
Second Address | Newhall, CA 91321-2538 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2019 |
Last Update Date | 04/04/2019 |