| NPI | 1114148020 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: WY LPC986) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WY LPC986, LAT333) |
| 101YP2500X Counselor, Professional (Licence: WY LPC-986) | |
| Enumeration Date | 2007-05-01 |
| Last Update Date | 2015-09-09 |