| NPI | 1023633005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: OR C10735) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR 21-10-10265) |
| Enumeration Date | 2020-06-15 |
| Last Update Date | 2026-07-21 |