| NPI | 1235725607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility |
| Enumeration Date | 2020-12-18 |
| Last Update Date | 2023-02-17 |