Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist |
NPI | 1730429663 |
---|---|
Provider Name | Mr. William Ellis Green SR. |
First Address | Lawton, OK 73505-9503 |
Second Address | Lawton, OK 73505-9503 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/03/2013 |
Last Update Date | 01/03/2013 |