| NPI | 1104033091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 1912) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: WI 6125) |
| Enumeration Date | 2007-05-17 |
| Last Update Date | 2007-07-08 |