| NPI | 1104177047 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MI 206486) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MI 6401001535) |
| 104100000X Social Worker (Licence: MI 6801057570) | |
| Enumeration Date | 2012-10-01 |
| Last Update Date | 2012-10-01 |