| NPI | 1184172702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR 16-R-37) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 301680) |
| Enumeration Date | 2016-09-12 |
| Last Update Date | 2016-09-12 |