| NPI | 1073519575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: WI 1391) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) |
| Enumeration Date | 2005-06-21 |
| Last Update Date | 2025-08-18 |