Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician |
NPI | 1003308644 |
---|---|
Provider Name | Mr. Brandon Paige |
First Address | Lake Mary, FL 32746-3625 |
Second Address | North Fort Myers, FL 33903 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/05/2018 |
Last Update Date | 30/05/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
009093700 | (05) | FL |