| NPI | 1720450943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: VA 0701005656) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0718000249) |
| Enumeration Date | 2015-10-27 |
| Last Update Date | 2015-10-27 |