| NPI | 1164612867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: LA 8205) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA 915) |
| Enumeration Date | 2007-07-29 |
| Last Update Date | 2007-07-29 |