| NPI | 1417116369 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: SD LPC1148) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: SD 5117) |
| Enumeration Date | 2008-06-05 |
| Last Update Date | 2008-06-05 |