| NPI | 1508119959 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: CO 11145) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: CO 315) |
| Enumeration Date | 2012-10-23 |
| Last Update Date | 2016-04-28 |