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Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
PHD

Contact information

Practice address
1 MEDICAL CENTER DR, LEBANON, NH 03756-0001
(603) 650-6176
Mailing address
1 MEDICAL CENTER DR, LEBANON, NH 03756-0001
(603) 650-6176

Taxonomy

Speciality
Code
Description
License number
State
103TA0400X
Addiction (Substance Use Disorder) Psychologist
Primary
0580
NH

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
30423610
NH
05
OVN2514
VT
Enumeration date
02/26/2007
Last updated
07/09/2007
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