| NPI | 1770745663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: KS 3793) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: KS 3793) |
| 101YM0800X Counselor Mental Health (Licence: KS 3793) | |
| Enumeration Date | 2008-07-01 |
| Last Update Date | 2019-12-10 |