| NPI | 1679779987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: KS 2281) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: MO 2006039002) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KS 538) | |
| Enumeration Date | 2007-06-23 |
| Last Update Date | 2016-05-12 |