Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | ||
Y | 101YM0800X | Mental Health Counselor | 10023 | MA |
NPI | 1003240193 |
---|---|
Provider Name | Mr. Bryan Smith |
First Address | Woburn, MA 01801-5901 |
Second Address | Woburn, MA 01801-5901 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/08/2013 |
Last Update Date | 30/09/2020 |