| NPI | 1295723781 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: AZ LISAC1620) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: AZ LPC0146) |
| Enumeration Date | 2005-10-10 |
| Last Update Date | 2007-07-08 |