| NPI | 1669957890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MD 12629) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MD LCA432) |
| Enumeration Date | 2018-10-03 |
| Last Update Date | 2018-10-03 |