| NPI | 1659484764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: WV 1641) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WV 81230) |
| Enumeration Date | 2006-08-16 |
| Last Update Date | 2024-11-29 |