| NPI | 1376081018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: MN 35384) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 17952-130) |
| Enumeration Date | 2017-02-02 |
| Last Update Date | 2025-09-30 |