| NPI | 1760148522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: NC 17217) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC LCAS-25438) |
| Enumeration Date | 2021-11-16 |
| Last Update Date | 2025-12-02 |