| NPI | 1194202317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: NC 14447) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 20651) |
| 101YM0800X Counselor, Mental Health (Licence: NC 20651) | |
| Enumeration Date | 2018-07-20 |
| Last Update Date | 2019-05-23 |