| NPI | 1235316456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: AZ 16036) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: TX 63481) |
| Enumeration Date | 2008-01-30 |
| Last Update Date | 2025-05-14 |