| NPI | 1720264302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: TX 70020) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0710102179) |
| Enumeration Date | 2008-01-14 |
| Last Update Date | 2024-03-12 |