| NPI | 1629044623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: IA 10R066) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 11462) |
| Enumeration Date | 2006-02-28 |
| Last Update Date | 2014-01-14 |