| NPI | 1083644645 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA 0189) | 
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: LA 4679) | 
| Enumeration Date | 2006-07-03 | 
| Last Update Date | 2025-09-11 |