| NPI | 1134226566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: LA LAC # 713) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: LA CCDP-D #1101) |
| 101Y00000X Counselor (Licence: LA CCS # 017) | |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2010-10-28 |