| NPI | 1134699028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301017696) |
| Enumeration Date | 2018-12-04 |
| Last Update Date | 2020-11-23 |