| NPI | 1154765386 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MD LC5756) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MD LCA2175) |
| Enumeration Date | 2013-04-18 |
| Last Update Date | 2020-09-14 |