| NPI | 1740400159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: WY 307) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WY PAT-014) |
| Enumeration Date | 2007-04-26 |
| Last Update Date | 2015-05-21 |