| NPI | 1124757422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: NM CSA0217411) |
| Additional Taxonomies | 164X00000X Licensed Vocational Nurse (Licence: NM LPN-22896) |
| Enumeration Date | 2022-06-10 |
| Last Update Date | 2022-12-20 |