| NPI | 1639293772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: WI 22-124) |
| 1041C0700X Social Worker, Clinical (Licence: WI 1997-123) | |
| Enumeration Date | 2007-03-16 |
| Last Update Date | 2007-07-08 |