| NPI | 1609361997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WY CAP-174) |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator |
| Enumeration Date | 2018-06-28 |
| Last Update Date | 2019-01-31 |