| NPI | 1023678539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: FL 50334) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: FL 4318) |
| Enumeration Date | 2019-06-17 |
| Last Update Date | 2019-06-17 |