| NPI | 1720673072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: CO LPC.0015500) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO ACD.0001840) |
| Enumeration Date | 2021-03-08 |
| Last Update Date | 2021-08-06 |