| NPI | 1609248962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: MI 6801097612) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MI 2-01111) |
| Enumeration Date | 2015-10-27 |
| Last Update Date | 2022-07-21 |