| NPI | 1215655352 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CA B00003650924) |
| Enumeration Date | 2022-08-15 |
| Last Update Date | 2025-08-18 |