| NPI | 1124476916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC1900X Psychologist, Counseling (Licence: VT 694) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VT 000030) |
| Enumeration Date | 2016-06-02 |
| Last Update Date | 2016-06-02 |