| NPI | 1093195810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: AZ LPC-14567) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: AZ LISAC-11892) |
| Enumeration Date | 2015-06-06 |
| Last Update Date | 2015-06-06 |