| NPI | 1508187220 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: AZ 17647) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: CO 333) |
| Enumeration Date | 2010-06-16 |
| Last Update Date | 2021-02-22 |