| NPI | 1639888530 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CA 7078) |
| Additional Taxonomies | 164X00000X Licensed Vocational Nurse (Licence: CA 221796) |
| Enumeration Date | 2022-11-18 |
| Last Update Date | 2026-03-11 |