Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health |
NPI | 1023527983 |
---|---|
Provider Name | Mr. Jean Alain Dagobert |
First Address | Brockton, MA 02302-2001 |
Second Address | Quincy, MA 02169-7482 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/09/2017 |
Last Update Date | 23/09/2017 |