| NPI | 1073602397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 541123) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: WI 541123) |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2008-02-27 |