| NPI | 1205485844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 104100000X Social Worker (Licence: NM SWB20230921) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: NM CAD0225341) |
| 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: NM CAD0225341) | |
| Enumeration Date | 2019-09-06 |
| Last Update Date | 2025-07-23 |