| NPI | 1770188310 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) |
| Additional Taxonomies | 103TA0400X Psychologist Addiction (Substance Use Disorder) |
| Enumeration Date | 2020-12-02 |
| Last Update Date | 2020-12-04 |