Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 0680000439 | VT |
NPI | 1003934084 |
---|---|
Provider Name | Brian Davis |
First Address | Wilmington, VT 05363-1664 |
Second Address | Brattleboro, VT 05301-8669 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2007 |
Last Update Date | 08/07/2007 |