| NPI | 1174541163 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: VA 0904001302) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: VA 0718000030) |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2010-12-27 |