| NPI | 1396397527 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: OH LCDCIII162380) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility (Licence: OH 170920) |
| Enumeration Date | 2019-07-09 |
| Last Update Date | 2025-03-07 |