| NPI | 1619742103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MD AC1841) |
| Additional Taxonomies | 103TA0400X Psychologist, Addiction (Substance Use Disorder) |
| Enumeration Date | 2023-11-15 |
| Last Update Date | 2023-11-15 |