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General NPI Number Information
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NPI Number | 1689942625
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Entity Type | Organization
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Legal Business Name | MARRIAGE & FAMILY THERAPY ASSOCIATES
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Dates
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Enumeration Date | 12/05/2011
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Last Update Date | 12/05/2011
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Provider Practice Location Address
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Address Line | 2 SOUTH ST STE 210
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City | AUBURN
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State | NY
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Zip | 13021-6174
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Country | US
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Telephone | 315-282-7076
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Fax |
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Provider Business Mailing Address
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Address Line | 2 SOUTH ST STE 210
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City | AUBURN
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State | NY
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Zip | 13021-6174
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Country | US
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Telephone | 315-282-7076
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. RICHARD NEWELL MACK
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Credential | M.DIV., LMFT
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Telephone | 315-282-7076
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 000906
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License Number State | NY
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