| NPI | 1013954775 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: FL MH 4657) | 
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) | 
| Enumeration Date | 2006-06-01 | 
| Last Update Date | 2025-07-29 |