| NPI | 1003079708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 15413-131) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 302375) |
| Enumeration Date | 2008-07-03 |
| Last Update Date | 2009-06-30 |