| NPI | 1538724711 |
|---|---|
| Professional Name | NONE NONE NONE |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: ME 6650) |
| Enumeration Date | 2019-05-03 |
| Last Update Date | 2019-05-03 |