| NPI | 1760886501 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: TX 66931) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: TX 12608) |
| Enumeration Date | 2014-10-21 |
| Last Update Date | 2015-09-02 |