| NPI | 1407636780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: TX 84789) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: TX 15503) |
| Enumeration Date | 2023-10-03 |
| Last Update Date | 2025-11-05 |