| NPI | 1376067942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: WI 6550-125) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 16168-132) |
| Enumeration Date | 2017-07-26 |
| Last Update Date | 2017-07-26 |