| NPI | 1407460231 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: NM X11280) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: NM CAD0195421) |
| Enumeration Date | 2020-08-31 |
| Last Update Date | 2020-08-31 |