| NPI | 1457367641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: VA 0701002545) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0718000066) |
| Enumeration Date | 2006-07-31 |
| Last Update Date | 2007-07-08 |