| NPI | 1376111773 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: MI 6401018451) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: PA 8135) |
| Enumeration Date | 2021-06-14 |
| Last Update Date | 2021-06-14 |