| NPI | 1114794088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 281821) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: KY 290104) |
| Enumeration Date | 2023-12-11 |
| Last Update Date | 2025-11-05 |