| NPI | 1164627683 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: NC 5480) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: NC 1088) |
| Enumeration Date | 2007-06-15 |
| Last Update Date | 2022-05-18 |