| NPI | 1316403892 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: CT 4530) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CT 001323) |
| Enumeration Date | 2019-02-20 |
| Last Update Date | 2025-07-18 |