| NPI | 1104381516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: NC A13943) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Enumeration Date | 2019-02-11 |
| Last Update Date | 2019-02-25 |