| NPI | 1184165052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: VA 0904011565) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0710102866) |
| Enumeration Date | 2017-03-13 |
| Last Update Date | 2022-02-28 |