| NPI | 1487697611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA LADAC1 # 75) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MA LMHC # 321) |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2007-07-08 |