| NPI | 1750655890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: MO 5653) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MO 4718) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MO 103) | |
| Enumeration Date | 2012-03-07 |
| Last Update Date | 2012-03-07 |