| NPI | 1104135532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MD 12722) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MD LCA418) |
| Enumeration Date | 2010-10-04 |
| Last Update Date | 2018-02-07 |