| NPI | 1245438712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: SC 4963) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility |
| Enumeration Date | 2007-07-06 |
| Last Update Date | 2011-01-23 |