| NPI | 1174766836 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: MD LC2546)  | 
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MD LCA462)  | 
| Enumeration Date | 2009-04-10 | 
| Last Update Date | 2009-04-10 |