| NPI | 1790201010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: ID LPC-6627) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0710102904) |
| Enumeration Date | 2017-08-17 |
| Last Update Date | 2017-08-17 |