Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1041C0700X | Clinical Social Worker | 113546 | MA |
Y | 1041C0700X | Clinical Social Worker | 2116 | NH |
NPI | 1003274507 |
---|---|
Provider Name | Kyle Boston |
First Address | Concord, NH 03302-2032 |
Second Address | Concord, NH 03301 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2016 |
Last Update Date | 22/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
113546 | LICSW LICENSE NUMBER (01) | MA |