| NPI | 1629065487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MT 1274) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MT 743) |
| Enumeration Date | 2005-10-05 |
| Last Update Date | 2017-02-22 |