Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003313495 |
---|---|
Provider Name | Kevin Fagundo |
First Address | Worcester, MA 01608-2419 |
Second Address | Westborough, MA 01581-3320 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2018 |
Last Update Date | 11/04/2018 |