| NPI | 1619386257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: CO 0012804) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO ACD.0000776) |
| Enumeration Date | 2014-08-07 |
| Last Update Date | 2021-03-31 |