| NPI | 1629711601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC LCAS-27309) |
| Enumeration Date | 2022-04-18 |
| Last Update Date | 2026-03-10 |