| NPI | 1386881795 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: MA 16) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 83) |
| Enumeration Date | 2009-01-08 |
| Last Update Date | 2015-10-07 |