| NPI | 1255758017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: NC 11106) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 20352) |
| Enumeration Date | 2014-03-18 |
| Last Update Date | 2019-03-27 |