| NPI | 1649460312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: AZ LPC-10063) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: AZ LISAC-10173) |
| Enumeration Date | 2007-07-30 |
| Last Update Date | 2007-07-30 |