| NPI | 1023194404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MA 107673) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 1028) |
| Enumeration Date | 2006-10-28 |
| Last Update Date | 2007-09-09 |