Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst |
NPI | 1003231127 |
---|---|
Provider Name | Mr. Scott Wiggins |
First Address | Belleville, IL 62221-4543 |
Second Address | Belleville, IL 62221-4543 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/02/2014 |
Last Update Date | 19/03/2015 |