| NPI | 1295071389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 167G00000X Licensed Psychiatric Technician |
| Enumeration Date | 2012-12-18 |
| Last Update Date | 2020-04-27 |