| NPI | 1013297803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: KY 104687) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: KY 167790) |
| Enumeration Date | 2011-08-24 |
| Last Update Date | 2024-04-12 |