| NPI | 1508864943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: VA 0701003771) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0701003771) |
| 101YP2500X Counselor, Professional (Licence: VA 0701003771) | |
| Enumeration Date | 2005-07-11 |
| Last Update Date | 2007-07-08 |