| NPI | 1053474940 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 17) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: MA 110003) |
| Enumeration Date | 2006-12-19 |
| Last Update Date | 2007-07-08 |