| NPI | 1104358167 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0710103065) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: VA 0704008801) |
| Enumeration Date | 2017-03-29 |
| Last Update Date | 2026-01-20 |