| NPI | 1699751750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: WY NCC 48217) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WY LAT 245) |
| 101YP2500X Counselor, Professional (Licence: WY LPC 672) | |
| Enumeration Date | 2005-12-21 |
| Last Update Date | 2007-07-08 |