| NPI | 1649334616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: VA 0701004116) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0701004116) |
| 101YM0800X Counselor, Mental Health (Licence: VA 0701004116) | |
| Enumeration Date | 2006-12-21 |
| Last Update Date | 2007-07-09 |