| NPI | 1124449541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: IA 001040) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: IA CDD09002) |
| Enumeration Date | 2014-01-02 |
| Last Update Date | 2014-01-02 |