| NPI | 1699170738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: TX 17916) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KS 00729) |
| 101YP2500X Counselor, Professional (Licence: KS 2869) | |
| Enumeration Date | 2014-10-31 |
| Last Update Date | 2020-12-11 |