| NPI | 1639644107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: ID LPC-6455) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: ID 1070) |
| Enumeration Date | 2018-10-10 |
| Last Update Date | 2018-10-10 |