| NPI | 1376868117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: AZ 11921) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: AZ 11502) |
| Enumeration Date | 2010-04-05 |
| Last Update Date | 2010-04-05 |