Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 450953 | MN |
NPI | 1053655159 |
---|---|
Provider Name | Mr. Juan Carlos Ortega |
First Address | Beverly, MA 01915-6175 |
Second Address | Beverly, MA 01915-6175 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2012 |
Last Update Date | 15/11/2012 |