| NPI | 1205877255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 101Y00000X Counselor (Licence: VA 0701002319) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: VA 0718000133) |
| Enumeration Date | 2006-06-09 |
| Last Update Date | 2007-07-08 |