| NPI | 1104018027 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NM 3918) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2007-08-14 |
| Last Update Date | 2019-09-19 |