| NPI | 1518401504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: VA 0904002765) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0710000721) |
| Enumeration Date | 2016-12-09 |
| Last Update Date | 2016-12-09 |