| NPI | 1710201645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: VA 0904007327) |
| Additional Taxonomies | 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: VA 0710102363) |
| Enumeration Date | 2010-03-22 |
| Last Update Date | 2010-03-22 |