| NPI | 1609307479 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: LA 6463) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA 1588) |
| Enumeration Date | 2017-03-23 |
| Last Update Date | 2017-03-23 |