Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 03050-T | KS |
Y | 103T00000X | Psychologist | 03050-T | KS |
NPI | 1013677723 |
---|---|
Provider Name | Shadow Love |
First Address | Mission, KS 66202-3299 |
Second Address | Olathe, KS 66061-3123 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/12/2021 |
Last Update Date | 21/12/2021 |