| NPI | 1619418761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 9694) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MA 9694) |
| 101YM0800X Counselor, Mental Health (Licence: MA 9694) | |
| Enumeration Date | 2017-03-09 |
| Last Update Date | 2019-02-22 |