| NPI | 1760675094 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: TX 92764) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: TX 12077) |
| Enumeration Date | 2007-08-21 |
| Last Update Date | 2025-05-14 |