| NPI | 1720611619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: WI 4573-226) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 19124-130) |
| Enumeration Date | 2020-02-19 |
| Last Update Date | 2020-02-19 |