| NPI | 1063159390 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0711000410) |
| Enumeration Date | 2022-05-18 |
| Last Update Date | 2022-10-11 |