| NPI | 1194294546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: MS 1864) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Enumeration Date | 2018-11-15 |
| Last Update Date | 2022-07-15 |