| NPI | 1124623319 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: FL MH21197) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: FL MCAP100243) |
| Enumeration Date | 2020-12-03 |
| Last Update Date | 2022-11-02 |