| NPI | 1134584154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA 1524) |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator (Licence: LA 1542) |
| Enumeration Date | 2015-12-17 |
| Last Update Date | 2020-07-22 |