| NPI | 1649791310 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: CT 46.003558) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CT 001211) |
| Enumeration Date | 2017-07-03 |
| Last Update Date | 2022-04-01 |