| NPI | 1639594302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: GA 03300) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: GA 155062) |
| 171M00000X Case Manager/Care Coordinator | |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OH CDCA172565) | |
| Enumeration Date | 2014-03-04 |
| Last Update Date | 2025-09-21 |