Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | CCJP | PA |
NPI | 1003210634 |
---|---|
Provider Name | Matthew Fox |
First Address | Harrisburg, PA 17101-2809 |
Second Address | Harrisburg, PA 17101-2809 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2014 |
Last Update Date | 10/10/2014 |