Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PS015472 | PA |
Y | 103TC0700X | Clinical Psychologist | PS015472 | PA |
NPI | 1003896614 |
---|---|
Provider Name | Shonda Nixon |
First Address | Philadelphia, PA 19144-4248 |
Second Address | Philadelphia, PA 19123-1957 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/01/2006 |
Last Update Date | 02/04/2008 |