| NPI | 1760873947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: VA 0701005973) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: VA 0710102467) |
| Enumeration Date | 2015-02-10 |
| Last Update Date | 2015-02-17 |