| NPI | 1700162542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: 00240-C) |
| Additional Taxonomies | 171W00000X Contractor |
| Enumeration Date | 2011-10-25 |
| Last Update Date | 2019-03-29 |