| NPI | 1770160467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health |
| Additional Taxonomies | 103T00000X Psychologist |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) | |
| Enumeration Date | 2021-03-27 |
| Last Update Date | 2021-03-27 |