Individual
BABA SY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
3760 W 74TH AVE, ANCHORAGE, AK 99502-2862
(907) 350-0061
(907) 868-1592
Mailing address
2025 E 73RD AVE APT 1, ANCHORAGE, AK 99507-2789
(907) 222-6855
(907) 222-2653
Taxonomy
Speciality
Code
Description
License number
State
103TA0700X
Adult Development & Aging Psychologist
978570
AK
372500000X
Chore Provider
Primary
—
AK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1417389511
—
AK
Enumeration date
07/31/2013
Last updated
07/14/2020
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