| NPI | 1063409571 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: FL 18198) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: TN 1141) |
| 101YP2500X Counselor Professional (Licence: TN 3137) | |
| 101YP2500X Counselor Professional (Licence: VA 0701008797) | |
| Enumeration Date | 2005-09-29 |
| Last Update Date | 2022-09-11 |