| NPI | 1356621072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: WI 7762123) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 15586132) |
| Enumeration Date | 2011-08-25 |
| Last Update Date | 2011-08-25 |