| NPI | 1215595004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: FL IMH17754) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Enumeration Date | 2019-06-05 |
| Last Update Date | 2019-08-20 |