| NPI | 1407051204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO 5928) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: CO 3336) |
| 324500000X Substance Abuse Rehabilitation Facility | |
| Enumeration Date | 2007-06-20 |
| Last Update Date | 2007-07-08 |