| NPI | 1780064014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VT 097-0134513) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NY 30794) |
| Enumeration Date | 2015-06-02 |
| Last Update Date | 2019-06-28 |