| NPI | 1558825893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: OH 314669) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Enumeration Date | 2019-01-30 |
| Last Update Date | 2020-01-21 |