| NPI | 1659768992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: NC C009401) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: NC C009401) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC LCAS-23275) | |
| Enumeration Date | 2015-04-24 |
| Last Update Date | 2020-03-26 |