| NPI | 1124455811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: AZ 63836) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: ID 10158) |
| Enumeration Date | 2013-09-26 |
| Last Update Date | 2013-09-26 |