| NPI | 1215359021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: NC 8464) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 3020-A) |
| Enumeration Date | 2014-01-13 |
| Last Update Date | 2014-01-13 |