Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor |
NPI | 1003178526 |
---|---|
Provider Name | Tammy Sue Korb |
First Address | Fairbanks, AK 99701-7530 |
Second Address | Fairbanks, AK 99701-7530 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2012 |
Last Update Date | 11/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MH0157 | (05) | AK |