| NPI | 1104543867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: NC 18142) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 30529) |
| Enumeration Date | 2022-10-24 |
| Last Update Date | 2025-12-08 |