| NPI | 1124207790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: FL CAP 1206) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: FL MH7746) |
| Enumeration Date | 2007-10-30 |
| Last Update Date | 2007-10-30 |