| NPI | 1104358738 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: CT 3519) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CT 1234) |
| 101YM0800X Counselor, Mental Health (Licence: CT 3519) | |
| Enumeration Date | 2017-04-02 |
| Last Update Date | 2023-07-14 |