| NPI | 1649299132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 1998) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: MA 34075) |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2007-07-08 |