| NPI | 1114568763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 303229) |
| Additional Taxonomies | 104100000X Social Worker (Licence: MN 26330) |
| Enumeration Date | 2019-10-04 |
| Last Update Date | 2019-10-04 |