| NPI | 1699163022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 1016) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 165945) |
| Enumeration Date | 2015-01-08 |
| Last Update Date | 2021-03-09 |