| NPI | 1083967079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: AZ LPC-1937) |
| Additional Taxonomies | 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: AZ LISAC-1446) |
| Enumeration Date | 2012-10-16 |
| Last Update Date | 2012-10-16 |