| NPI | 1174336820 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 282007) |
| Additional Taxonomies | 251S00000X Community/Behavioral Health (Licence: KY CSA) |
| Enumeration Date | 2025-01-28 |
| Last Update Date | 2025-10-08 |