| NPI | 1730495979 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO 6918)  | 
| Additional Taxonomies | 101Y00000X Counselor | 
| Enumeration Date | 2010-08-25 | 
| Last Update Date | 2010-08-25 |