| NPI | 1083908594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MA 265) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MA 40) |
| 106H00000X Marriage & Family Therapist (Licence: MA 149) | |
| Enumeration Date | 2011-06-01 |
| Last Update Date | 2011-06-01 |