| NPI | 1013543560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: VA 0701011044) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0709024298) |
| Enumeration Date | 2020-03-17 |
| Last Update Date | 2023-11-15 |