| NPI | 1619604758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: VA 0701013640) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0710103168) |
| Enumeration Date | 2022-08-08 |
| Last Update Date | 2024-09-26 |