| NPI | 1053300707 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: AZ LISAC1228) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: AZ LPC11103) |
| Enumeration Date | 2005-10-17 |
| Last Update Date | 2007-07-08 |