| NPI | 1376187161 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility (Licence: OH 170101) |
| Enumeration Date | 2019-11-05 |
| Last Update Date | 2026-07-23 |