| NPI | 1659577229 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MA C-4356) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MA LADC1#129) |
| Enumeration Date | 2007-06-21 |
| Last Update Date | 2007-07-08 |