| NPI | 1265705859 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: LA 4089) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA 1309) |
| Enumeration Date | 2012-02-14 |
| Last Update Date | 2012-02-14 |