| NPI | 1104825868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0710000295) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: VA 0904003777) |
| Enumeration Date | 2005-07-15 |
| Last Update Date | 2025-09-11 |