| NPI | 1073856191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: IA 075768) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NE 890) |
| Enumeration Date | 2013-03-27 |
| Last Update Date | 2018-06-11 |