Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YS0200X | School Counselor | AZ |
NPI | 1053445569 |
---|---|
Provider Name | Mr. Joseph H Kenrick |
First Address | Wickenburg, AZ 85358-0487 |
Second Address | Wickenburg, AZ 85390 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/03/2007 |
Last Update Date | 26/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
103411 | AHCCCS PROVIDER NUMBER (01) | AZ |