| NPI | 1124418298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MT BBH-LCSW-LIC-42723) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MT LAC-LAC-LIC-4244) |
| Enumeration Date | 2015-01-28 |
| Last Update Date | 2020-04-06 |