| NPI | 1568564508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: LA 4537) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: LA 27) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA 782) | |
| Enumeration Date | 2006-09-01 |
| Last Update Date | 2011-08-11 |