| NPI | 1548808280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: SC 11041) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 245401) |
| Enumeration Date | 2019-12-12 |
| Last Update Date | 2025-07-31 |