| NPI | 1104243617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: NC 10342) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC LCAS-21612) |
| Enumeration Date | 2014-03-21 |
| Last Update Date | 2022-06-01 |