| NPI | 1164585998 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: WI 3140-125) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 12719) |
| Enumeration Date | 2006-12-19 |
| Last Update Date | 2007-07-24 |