| NPI | 1659776292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: TX 65218) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: TX 2019) |
| Enumeration Date | 2014-10-24 |
| Last Update Date | 2014-10-24 |