Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | PY00348 | MO |
N | 103T00000X | Psychologist | PY00348 | MO |
N | 103G00000X | Clinical Psychologist | PY00348 | MO |
N | 103TC0700X | Clinical Psychologist | PY00348 | MO |
N | 103TH0100X | Health Service | PY00348 | MO |
NPI | 1245226745 |
---|---|
Provider Name | Mr. John Michael Wubbenhorst SR. |
First Address | Kansas City, MO 64111-2658 |
Second Address | Kansas City, MO 64111-2658 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/09/2005 |
Last Update Date | 08/07/2007 |