| NPI | 1306832704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: AZ LPC-10810) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: AZ LISAC-10577) |
| Enumeration Date | 2005-09-22 |
| Last Update Date | 2012-04-30 |