| NPI | 1144004912 |
|---|---|
| Professional Name | NONE NONE NONE |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: TX 14828) |
| Enumeration Date | 2023-08-23 |
| Last Update Date | 2023-08-24 |