Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist |
NPI | 1548600943 |
---|---|
Provider Name | Tara Boyle |
First Address | Las Vegas, NV 89120-3930 |
Second Address | Las Vegas, NV 89120-4932 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2013 |
Last Update Date | 28/06/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1700046372 | (05) | NV |