| NPI | 1366964868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: GA LPC015169) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: GA 3419) |
| Enumeration Date | 2017-07-17 |
| Last Update Date | 2025-01-06 |