Healthcare Provider Details

I. General information

NPI: 1538631999
Provider Name (Legal Business Name): ROBERT MARK ETRE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2018
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 BEECH ST
HOLYOKE MA
01040-3968
US

IV. Provider business mailing address

319 BEECH ST
HOLYOKE MA
01040-3968
US

V. Phone/Fax

Practice location:
  • Phone: 413-540-1160
  • Fax: 413-533-1016
Mailing address:
  • Phone: 413-540-1160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: