Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst | BACB415523 | CA |
NPI | 1003587221 |
---|---|
Provider Name | Nicole Wentz |
First Address | Stuart, FL 34997-7462 |
Second Address | San Jose, CA 95119-1371 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2021 |
Last Update Date | 27/09/2021 |