Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 6648 | MA |
N | 103T00000X | Psychologist | 6648 | MA |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 415 | MA |
NPI | 1265500508 |
---|---|
Provider Name | Dr. Jane Dreeben |
First Address | West Tisbury, MA 02575-0516 |
Second Address | Vineyard Haven, MA 02568 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
W05885 | BLUE CROSS BLUE SHIELD (01) | MA |