| NPI | 1194097022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC LCAS 3014) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: NC 4360) |
| Enumeration Date | 2012-02-08 |
| Last Update Date | 2016-01-27 |