| NPI | 1568505923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: VA 0701003786) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0710001240) |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2008-01-09 |