IMAT R AMIDJAYA Clinical Psychologist License verification

Business Entity

NOT RENEWED

License Type

Clinical Psychologist

Description

CLINICAL PSYCHOLOGIST

License Number

071002036

License Status

NOT RENEWED

Business

First Name

IMAT R

Last Name

AMIDJAYA

Business Name

IMAT R AMIDJAYA

Original Issue Date

12/28/1976

Effective Date

10/07/2004

Expiration Date

09/30/2006

City

ROCKFORD

State

Zip

61107

County

WINNEBAGO

Ever Disciplined

LastModifiedDate

11/08/2006