| NPI | 1770882755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: OK 5683) |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OK 1092) | |
| Enumeration Date | 2011-03-16 |
| Last Update Date | 2015-12-08 |