Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | PSY14143 | CA |
Y | 103T00000X | Psychologist | PSY14143 | CA |
NPI | 1013261932 |
---|---|
Provider Name | Robert Fish |
First Address | Los Angeles, CA 90039-1825 |
Second Address | Los Angeles, CA 90013-2102 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/10/2012 |
Last Update Date | 30/10/2012 |