| NPI | 1770835910 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: CO 12353) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: CO 13670) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO 6941) | |
| Enumeration Date | 2012-10-12 |
| Last Update Date | 2015-03-25 |