| NPI | 1073975389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: IA 079514) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: IA 14020) |
| Enumeration Date | 2016-03-25 |
| Last Update Date | 2016-03-25 |