| NPI | 1710023148 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 301392) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: WI 2832-125) |
| Enumeration Date | 2007-01-30 |
| Last Update Date | 2007-07-08 |