| NPI | 1770715211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 10145) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MA 10145) |
| Enumeration Date | 2009-08-18 |
| Last Update Date | 2018-07-11 |