Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 2384582 | IL |
NPI | 1063928398 |
---|---|
Provider Name | Shawnna Brown |
First Address | Rockford, IL 61108-3705 |
Second Address | Belvidere, IL 61008-9735 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/12/2017 |
Last Update Date | 22/12/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1811165061 | (05) | IL |