| NPI | 1578945994 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: SC 11230) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: SC 762) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 21181) | |
| Enumeration Date | 2015-06-22 |
| Last Update Date | 2023-07-26 |