| NPI | 1609867761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 10679-132) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: WI 1308-120) |
| Enumeration Date | 2005-10-28 |
| Last Update Date | 2020-05-13 |