| NPI | 1770066417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OH CDCA.171546) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: OH QMHS) |
| 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: OH 2018) | |
| Enumeration Date | 2018-09-10 |
| Last Update Date | 2025-06-05 |