| NPI | 1710411251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 171999) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 128572) |
| Enumeration Date | 2017-04-11 |
| Last Update Date | 2018-07-02 |