| NPI | 1104136571 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: AZ LISAC10856) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: AZ LPC11260) |
| Enumeration Date | 2010-10-19 |
| Last Update Date | 2010-10-19 |