| NPI | 1396011631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR 08-12-39) |
| Enumeration Date | 2012-03-30 |
| Last Update Date | 2015-02-10 |