| NPI | 1083941389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: WY LPC-519) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WY 512) |
| 101YP2500X Counselor, Professional (Licence: WY 512) | |
| Enumeration Date | 2009-11-06 |
| Last Update Date | 2012-10-23 |