Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 419456309 | NY |
NPI | 1003246307 |
---|---|
Provider Name | Jeremy Thompson |
First Address | Mamaroneck, NY 10543-4325 |
Second Address | Mount Vernon, NY 10550-3303 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/11/2013 |
Last Update Date | 22/11/2013 |