| NPI | 1720611775 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: GA CSW007990) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: GA CSW007990) |
| Enumeration Date | 2020-02-18 |
| Last Update Date | 2025-07-28 |