Individual
RUSSELL JEREMY GWILLIAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MA, LMHC
Contact information
Practice address
44 FRONT ST, WORCESTER, MA 01608-1733
(508) 753-0321
Mailing address
12 PINEVIEW TRL, AUBURN, MA 01501-2120
(508) 864-0839
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
1745
MA
Other
Enumeration date
09/09/2010
Last updated
09/09/2010
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