| NPI | 1275959421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: GA LPC007699) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: GA CAADC) |
| Enumeration Date | 2014-03-12 |
| Last Update Date | 2014-12-10 |