| NPI | 1679813554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: WY LPC-1338) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: WY MAC-509958) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WY CAP-112) | |
| Enumeration Date | 2013-02-28 |
| Last Update Date | 2018-08-16 |