| NPI | 1629510987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: IA 072294) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: IA 14107) |
| Enumeration Date | 2016-11-17 |
| Last Update Date | 2016-11-17 |