| NPI | 1770624504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: VA 0904004948) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: VA 0710001284) |
| Enumeration Date | 2007-02-12 |
| Last Update Date | 2008-09-26 |