| NPI | 1063634491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: AK TTS02-09-006P) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: AK CDC 1 3614) |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2010-01-19 |