| NPI | 1013484054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| 106S00000X Behavior Technician | |
| Enumeration Date | 2018-10-29 |
| Last Update Date | 2018-10-29 |