Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 1957 | MA |
Y | 103T00000X | Psychologist | 1957 | MA |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 1957 | MA |
NPI | 1568609865 |
---|---|
Provider Name | Dr. Stephen K. Valle |
First Address | Lynn, MA 01905-2506 |
Second Address | Lynn, MA 01905-2506 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/01/2009 |
Last Update Date | 08/01/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
W10202 | BLUE CROSS BLUE SHIELD OF MASSACHUSETTS (01) | MA |