| NPI | 1225393267 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO 5177) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: CO 2188) |
| Enumeration Date | 2012-07-05 |
| Last Update Date | 2012-07-05 |