| NPI | 1699214288 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: KY 268090) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 171574) |
| Enumeration Date | 2017-02-16 |
| Last Update Date | 2021-01-22 |