| NPI | 1134791080 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: NC A17103) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC LCAS-27181) |
| Enumeration Date | 2021-07-12 |
| Last Update Date | 2026-06-03 |