| NPI | 1063939817 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: MO 202404464) |
| Enumeration Date | 2017-08-23 |
| Last Update Date | 2025-04-11 |