| NPI | 1558718825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: TX 16667) |
| Additional Taxonomies | 222Q00000X Developmental Therapist |
| Enumeration Date | 2016-05-17 |
| Last Update Date | 2023-09-02 |