| NPI | 1730515339 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 16954-130) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility (Licence: WI 16954-130) |
| Enumeration Date | 2013-09-16 |
| Last Update Date | 2013-09-16 |