| NPI | 1083135636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: KY 162868) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 168467) |
| Enumeration Date | 2017-07-05 |
| Last Update Date | 2026-06-29 |