| NPI | 1053479915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: ME LC3744) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: ME LC901) |
| 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: ME CCS3537) | |
| Enumeration Date | 2006-12-04 |
| Last Update Date | 2016-02-02 |