| NPI | 1265733091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: VA 0701004463) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: VA 0710101681) |
| Enumeration Date | 2010-11-10 |
| Last Update Date | 2013-09-05 |