| NPI | 1265803589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: VA 0701006303) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0710102912) |
| Enumeration Date | 2015-10-13 |
| Last Update Date | 2015-10-13 |