| NPI | 1245762541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: CO LPC.0014097) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: CO ACD.000926) |
| Enumeration Date | 2017-03-28 |
| Last Update Date | 2018-12-22 |