| NPI | 1497938864 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: 5569) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: CO 5569) |
| Enumeration Date | 2007-12-08 |
| Last Update Date | 2017-01-24 |