| NPI | 1720384605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: SC 6167) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: SC 105) |
| Enumeration Date | 2011-02-10 |
| Last Update Date | 2023-11-28 |