| NPI | 1497313456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: MD LC11805) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Enumeration Date | 2019-06-04 |
| Last Update Date | 2022-09-07 |