| NPI | 1376550541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: GA 003696) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: GA Certification #12786) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2021-07-10 |