| NPI | 1275650749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: AZ 10540) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: AZ 11790) |
| 103TC0700X Psychologist Clinical (Licence: AZ 3015) | |
| Enumeration Date | 2007-03-22 |
| Last Update Date | 2007-07-08 |