| NPI | 1003109588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) |
| Additional Taxonomies | 101YP2500X Counselor Professional |
| Enumeration Date | 2011-05-17 |
| Last Update Date | 2012-08-20 |