| NPI | 1750759619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: UT 8069600-3501) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: TX 64130) |
| Enumeration Date | 2015-09-09 |
| Last Update Date | 2025-07-14 |