| NPI | 1184052433 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: OR L6240) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR 10-06-80) |
| Enumeration Date | 2013-10-24 |
| Last Update Date | 2015-03-13 |