Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist |
NPI | 1043345218 |
---|---|
Provider Name | Mr. Gregory S Wilson |
First Address | Chandler, AZ 85224-6178 |
Second Address | Chandler, AZ 85224-6178 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/02/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
952243 | (05) | AZ |