| NPI | 1790862373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: FL 2588L) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: FL MH7161) |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2025-09-11 |