| NPI | 1588196604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: WV 1147) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: WV 1147) |
| Enumeration Date | 2017-03-29 |
| Last Update Date | 2017-03-29 |