| NPI | 1154539120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 12095) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: WI 1388) |
| 106H00000X Marriage & Family Therapist (Licence: WI 246) | |
| Enumeration Date | 2007-05-21 |
| Last Update Date | 2007-07-08 |