| NPI | 1720457062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: NM T-CTL0220731) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NM CSA0221391) |
| Enumeration Date | 2015-09-16 |
| Last Update Date | 2022-08-10 |