Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician |
NPI | 1003321274 |
---|---|
Provider Name | Tyler Martin |
First Address | Fairbanks, AK 99709-4701 |
Second Address | Fairbanks, AK 99709-4701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/12/2017 |
Last Update Date | 08/12/2017 |