Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor | CO |
NPI | 1255722989 |
---|---|
Provider Name | Randall Flynt |
First Address | Pueblo, CO 81008-2193 |
Second Address | Pueblo, CO 81008-2193 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/02/2015 |
Last Update Date | 17/02/2015 |