| NPI | 1184788895 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MI MDAC101986) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MI 4704107033) |
| 364SP0808X Clinical Nurse Specialist, Psych/Mental Health (Licence: MI 0205300-01) | |
| Enumeration Date | 2006-12-20 |
| Last Update Date | 2007-07-08 |