| NPI | 1275203168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: CT 005996) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CT 001422) |
| Enumeration Date | 2021-09-14 |
| Last Update Date | 2026-03-18 |