| NPI | 1114433281 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: TN 1600) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: TN TN-068) |
| 101YM0800X Counselor Mental Health (Licence: TN 7385) | |
| 175T00000X Peer Specialist (Licence: TN 000-1142) | |
| Enumeration Date | 2017-12-27 |
| Last Update Date | 2024-09-03 |