| NPI | 1780219642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: VA 0704012886) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0718000467) |
| Enumeration Date | 2020-03-11 |
| Last Update Date | 2023-08-25 |