| NPI | 1164040614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 101Y00000X Counselor |
| 101YP2500X Counselor, Professional | |
| Enumeration Date | 2020-07-10 |
| Last Update Date | 2020-07-10 |