| NPI | 1205851045 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MD LCA059) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MD 4126) |
| Enumeration Date | 2006-07-13 |
| Last Update Date | 2020-02-24 |