| NPI | 1124482401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: MT BBH-LCSW-LIC-16707) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MT LAC-LAC-LIC-3435) |
| Enumeration Date | 2016-04-12 |
| Last Update Date | 2016-10-17 |