| NPI | 1104394402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: PA PC000172) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) |
| Enumeration Date | 2018-11-05 |
| Last Update Date | 2020-03-02 |