| NPI | 1629355870 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MI 6401007537) |
| Additional Taxonomies | 103TC1900X Psychologist, Counseling (Licence: MI 6301005272) |
| Enumeration Date | 2011-11-15 |
| Last Update Date | 2011-11-15 |