| NPI | 1770504706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 0773) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: KY 1273) |
| Enumeration Date | 2006-07-23 |
| Last Update Date | 2007-07-08 |