=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326580432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCHESTER EVIDENCE-BASED PSYCHOTHERAPY CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2016
-----------------------------------------------------
Last Update Date | 06/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 414 S MAIN ST SUITE 201
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-568-5180
-----------------------------------------------------
Fax | 248-429-2132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 414 S MAIN ST SUITE 201
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48307-2068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-568-5180
-----------------------------------------------------
Fax | 248-429-2132
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ADAM G. HAMILTON
-----------------------------------------------------
Credential | MA, LPC, LLMFT, NCC
-----------------------------------------------------
Telephone | 248-568-5180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 4101006671
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401011306
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------