| NPI | 1790207058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: CSW02855) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: RI CDP00695) |
| Enumeration Date | 2017-07-07 |
| Last Update Date | 2025-03-12 |