| NPI | 1265620611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: NC 5084) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 6103353) |
| Enumeration Date | 2007-10-11 |
| Last Update Date | 2010-04-07 |