| NPI | 1659360642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 0436) |
| Additional Taxonomies | 106H00000X Marriage & Family Therapist (Licence: KY 0485) |
| Enumeration Date | 2005-10-21 |
| Last Update Date | 2007-07-08 |