Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 19327-130 | WI |
Y | 101YM0800X | Mental Health Counselor | 4984-226 | WI |
NPI | 1003484478 |
---|---|
Provider Name | Mr. John Barajas |
First Address | Green Bay, WI 54301-4054 |
Second Address | Green Bay, WI 54301-4054 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2021 |
Last Update Date | 14/06/2021 |