Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 1057713 | IL |
NPI | 1083184337 |
---|---|
Provider Name | Nicole Marie Smith |
First Address | Bigfork, MT 59911-3663 |
Second Address | Bigfork, MT 59911-3663 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2018 |
Last Update Date | 29/11/2018 |