| NPI | 1639628241 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: IL 180.011893) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 17477-130) |
| 101YP2500X Counselor, Professional (Licence: WI 2618-226) | |
| Enumeration Date | 2016-09-23 |
| Last Update Date | 2026-06-16 |