| NPI | 1760123574 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 1041C0700X Social Worker, Clinical | 
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: TX 16072) | 
| Enumeration Date | 2022-04-05 | 
| Last Update Date | 2025-07-30 |