| NPI | 1003261447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 305R00000X Preferred Provider Organization |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) | |
| Enumeration Date | 2016-05-03 |
| Last Update Date | 2026-08-28 |