| NPI | 1679112569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: CT 5365) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CT 1359) |
| Enumeration Date | 2019-12-26 |
| Last Update Date | 2023-03-16 |