| NPI | 1003866708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: OR L0525) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: OR 01-11-26) |
| Enumeration Date | 2006-05-11 |
| Last Update Date | 2007-07-08 |