Basic Information
| Provider Information | |||||||||
| NPI: | 1215906177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOOT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 WEST STREET | ||||||||
| Address2: | STE 29 | ||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033571180 | ||||||||
| FaxNumber: | 6033571185 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 WEST STREET | ||||||||
| Address2: | STE 29 | ||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033571180 | ||||||||
| FaxNumber: | 6033571185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP927 | NH | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 30420889 | 05 | NH | MEDICAID |