| NPI | 1134645856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 19440) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: RI CSW04273) |
| Enumeration Date | 2017-08-15 |
| Last Update Date | 2026-08-05 |