| NPI | 1710021035 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MD L1492) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MD LCA386) |
| Enumeration Date | 2007-02-19 |
| Last Update Date | 2019-10-23 |