Provider Demographics
NPI:1326580432
Name:ROCHESTER EVIDENCE-BASED PSYCHOTHERAPY CLINIC, PLLC
Entity Type:Organization
Organization Name:ROCHESTER EVIDENCE-BASED PSYCHOTHERAPY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, LLMFT, NCC
Authorized Official - Phone:248-568-5180
Mailing Address - Street 1:414 S MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2068
Mailing Address - Country:US
Mailing Address - Phone:248-568-5180
Mailing Address - Fax:248-429-2132
Practice Address - Street 1:414 S MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307
Practice Address - Country:US
Practice Address - Phone:248-568-5180
Practice Address - Fax:248-429-2132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011306101YP2500X
MI4101006671106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1417247768OtherINDIVIDUAL NPI