| NPI | 1073857785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: AL .908) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: AL NCC29568) |
| Enumeration Date | 2012-11-19 |
| Last Update Date | 2012-11-19 |