| NPI | 1083930192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MA 9039) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MA 2411) |
| Enumeration Date | 2010-04-14 |
| Last Update Date | 2015-07-21 |