| NPI | 1255467353 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: TX 89596) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: TX 10302) |
| 261QM0801X Clinic/Center Mental Health (Including Community Mental Health Center) (Licence: TX 89596) | |
| 261QM0850X Clinic/Center Adult Mental Health (Licence: TX 89596) | |
| 261QM0855X Clinic/Center Adolescent and Children Mental Health (Licence: TX 89596) | |
| 261QR0405X Clinic/Center Rehabilitation, Substance Use Disorder (Licence: TX 10302) | |
| Enumeration Date | 2007-02-26 |
| Last Update Date | 2024-06-27 |