| NPI | 1003261447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 305R00000X Preferred Provider Organization |
| Enumeration Date | 2016-05-03 |
| Last Update Date | 2020-01-22 |