| NPI | 1679980031 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: TX 72717) |
| Additional Taxonomies | 3245S0500X Substance Abuse Rehabilitation Facility, Substance Abuse Treatment, Children (Licence: TX 11953) |
| Enumeration Date | 2014-07-17 |
| Last Update Date | 2020-06-05 |