| NPI | 1356843767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA 5039) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA 4118) |
| Enumeration Date | 2018-03-01 |
| Last Update Date | 2021-08-10 |