| NPI | 1740567072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: ME LC12768) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: ME LC4928) |
| Enumeration Date | 2011-11-15 |
| Last Update Date | 2011-11-16 |