Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YM0800X | Mental Health Counselor | ||
Y | 1041C0700X | Clinical Social Worker | 10681 | CT |
NPI | 1003187196 |
---|---|
Provider Name | Ryan Shook |
First Address | Madison, CT 06443-2675 |
Second Address | Madison, CT 06443-2675 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/01/2012 |
Last Update Date | 02/07/2019 |