| NPI | 1013255561 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: CO LPC-11303) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: CO ACB-7483) |
| Enumeration Date | 2013-01-17 |
| Last Update Date | 2013-01-17 |