| NPI | 1063771558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MD LC3571) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MD LCA1786) |
| Enumeration Date | 2012-05-03 |
| Last Update Date | 2020-09-01 |