| NPI | 1003353343 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: VA 0701006954) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: VA 0710001282) |
| Enumeration Date | 2017-01-25 |
| Last Update Date | 2017-01-25 |