| NPI | 1710624820 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: KY 258549) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 275570) |
| Enumeration Date | 2022-05-19 |
| Last Update Date | 2024-02-23 |