Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst |
NPI | 1013330265 |
---|---|
Provider Name | Mr. Clinton Anthony Rossum JR. |
First Address | North Las Vegas, NV 89031-6894 |
Second Address | North Las Vegas, NV 89031-6894 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2014 |
Last Update Date | 23/01/2014 |