| NPI | 1235480237 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: WI 449689) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 15918-132) |
| Enumeration Date | 2012-10-01 |
| Last Update Date | 2019-09-17 |