| NPI | 1164813580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: CO LPC.0012438) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO 0007816) |
| Enumeration Date | 2015-02-06 |
| Last Update Date | 2019-01-09 |