| NPI | 1225780703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: TX 87819) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: TX 16031) |
| Enumeration Date | 2022-01-25 |
| Last Update Date | 2023-10-13 |