| NPI | 1104063338 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: WY LPC-752) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WY 752) |
| Enumeration Date | 2009-01-09 |
| Last Update Date | 2019-08-01 |