| NPI | 1558695650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: ME CC1560) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: ME LC1428) |
| Enumeration Date | 2009-09-23 |
| Last Update Date | 2015-08-27 |