| NPI | 1477789550 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: AZ LAC1300) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: AZ LISAC11859) |
| Enumeration Date | 2009-06-03 |
| Last Update Date | 2009-06-03 |