| NPI | 1205101508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171M00000X Case Manager/Care Coordinator |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WY CAP-123) |
| 101YP2500X Counselor, Professional (Licence: WY 1773) | |
| Enumeration Date | 2012-03-20 |
| Last Update Date | 2019-04-01 |