| NPI | 1053749168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: GA 9583) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: GA C0212) |
| Enumeration Date | 2013-10-29 |
| Last Update Date | 2018-11-01 |