| NPI | 1497028427 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: GA CSW004673) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: GA CERTIFICATE #227) |
| Enumeration Date | 2012-02-22 |
| Last Update Date | 2012-12-14 |