Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 2360793 | IL |
NPI | 1013423847 |
---|---|
Provider Name | Vincent Miller |
First Address | Bolingbrook, IL 60440-3071 |
Second Address | Bolingbrook, IL 60440-3071 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2017 |
Last Update Date | 15/12/2017 |