| NPI | 1659797819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: MS C7488) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MS AD03-35M) |
| Enumeration Date | 2014-03-12 |
| Last Update Date | 2024-02-12 |