| NPI | 1518534809 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty (Licence: CA 96000115) |
| Enumeration Date | 2021-06-07 |
| Last Update Date | 2024-12-06 |