Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC2200X | Clinical Child & Adolescent Psychologist |
NPI | 1083199616 |
---|---|
Provider Name | Vivian Song |
First Address | Brooklyn, NY 11201-4709 |
Second Address | Brooklyn, NY 11201-4709 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/09/2018 |
Last Update Date | 29/09/2018 |