| NPI | 1417407297 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: WI 3039-226) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: WI 17863-130) |
| Enumeration Date | 2016-10-05 |
| Last Update Date | 2016-10-05 |