| NPI | 1104863596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 13936131) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: WI 7117123) |
| Enumeration Date | 2006-06-02 |
| Last Update Date | 2007-12-19 |