| NPI | 1528414380 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MI 6401013603) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MI C-03082) |
| Enumeration Date | 2016-05-11 |
| Last Update Date | 2016-05-11 |