| NPI | 1003364969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261Q00000X Clinic/Center |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MO 9374) |
| 101YP2500X Counselor, Professional (Licence: MO 9374) | |
| 171M00000X Case Manager/Care Coordinator | |
| 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) | |
| Enumeration Date | 2016-09-20 |
| Last Update Date | 2019-09-19 |