Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TB0200X | Cognitive & Behavioral Psychologist |
NPI | 1174740625 |
---|---|
Provider Name | Mr. David Silas Green |
First Address | Aiken, SC 29803-8828 |
Second Address | Aiken, SC 29801 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
WP8977 | (05) | SC |