| NPI | 1104547991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 261QM0850X Clinic/Center, Adult Mental Health |
| 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-09-08 |
| Last Update Date | 2024-01-10 |