Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist |
NPI | 1053081711 |
---|---|
Provider Name | Stacey Romick-Imig |
First Address | Espanola, NM 87532-2656 |
Second Address | Espanola, NM 87532-2656 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2021 |
Last Update Date | 15/09/2021 |