| NPI | 1770684094 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: FL rn1914042) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: IL 041-160831) |
| 163WA0400X Registered Nurse, Addiction (Substance Use Disorder) (Licence: FL rn1914042) | |
| Enumeration Date | 2006-09-26 |
| Last Update Date | 2007-07-08 |