| NPI | 1053942748 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: CO LPC.0020691) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO ACD.0002083) |
| Enumeration Date | 2020-01-31 |
| Last Update Date | 2024-07-24 |