Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003294984 |
---|---|
Provider Name | Trisha Johnson |
First Address | Pawtucket, RI 02860-5542 |
Second Address | Pawtucket, RI 02860-5542 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2015 |
Last Update Date | 12/05/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
GH57134 | (05) | RI |