| NPI | 1164404836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: OR 1706) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR 02-03-28) |
| Enumeration Date | 2005-11-17 |
| Last Update Date | 2012-09-06 |