| NPI | 1023092335 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NY 8778) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MI 1234436) |
| Enumeration Date | 2005-11-30 |
| Last Update Date | 2007-07-08 |