| NPI | 1518489590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: IL 178013571) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: IL 30556) |
| Enumeration Date | 2017-07-12 |
| Last Update Date | 2018-10-17 |