| NPI | 1598835928 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: NC 5440) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: VA 0701005135) |
| 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: NC 1868) | |
| Enumeration Date | 2006-11-09 |
| Last Update Date | 2012-01-26 |