| NPI | 1760171268 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: LA LPC9395) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA CIT-5517) |
| Enumeration Date | 2023-05-02 |
| Last Update Date | 2025-09-09 |