| NPI | 1245567718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MD LCO307) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MD LCO307) |
| Enumeration Date | 2009-11-04 |
| Last Update Date | 2011-12-15 |