| NPI | 1134171861 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: ND 1239) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: ND 124) |
| Enumeration Date | 2006-05-17 |
| Last Update Date | 2007-07-08 |