| NPI | 1366033607 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JAMIE LEA FORTHMAN Credentialing Manager 270-557-6396 |
| Organization Subpart ? | No |
| Primary Taxonomy | 103T00000X Psychologist |
| Additional Taxonomies | 103TB0200X Psychologist, Cognitive & Behavioral |
| 103K00000X Behavior Analyst | |
| 103TC0700X Psychologist, Clinical | |
| 103TC2200X Psychologist, Clinical Child & Adolescent | |
| 103TH0004X Psychologist, Health | |
| 103TS0200X Psychologist, School | |
| Enumeration Date | 2021-01-29 |
| Last Update Date | 2021-04-07 |