Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 016782 | NY |
Y | 103T00000X | Psychologist | 016782 | NY |
N | 102L00000X | Psychologist | PY4748 | FL |
N | 103T00000X | Psychologist | PY4748 | FL |
NPI | 1003923889 |
---|---|
Provider Name | Theodore Michael Ines |
First Address | Troy, NY 12180-2466 |
Second Address | Troy, NY 12180-2466 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2006 |
Last Update Date | 08/07/2007 |