| NPI | 1780187401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: VA 0710103129) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: VA 2058) |
| Enumeration Date | 2018-03-09 |
| Last Update Date | 2018-03-09 |