| NPI | 1609443175 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: CT 15599) | 
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CT 001402) | 
| Enumeration Date | 2021-06-04 | 
| Last Update Date | 2025-08-02 |