| NPI | 1619367653 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: CO 0012034) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO 0000812) |
| Enumeration Date | 2015-01-29 |
| Last Update Date | 2024-10-22 |