| NPI | 1659795003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 106H00000X Marriage & Family Therapist (Licence: WI 1064-124) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: WI 17046-130) |
| Enumeration Date | 2014-02-05 |
| Last Update Date | 2016-03-28 |