| NPI | 1255677563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: WI 6023-125) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 16255-132) |
| Enumeration Date | 2012-12-14 |
| Last Update Date | 2018-08-13 |