| NPI | 1366007544 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MT 37251) |
| Additional Taxonomies | 175T00000X Peer Specialist (Licence: MT 32804) |
| Enumeration Date | 2019-05-03 |
| Last Update Date | 2019-05-03 |