| NPI | 1811295579 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 14221) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: RI CDP00493) |
| Enumeration Date | 2011-03-04 |
| Last Update Date | 2019-06-03 |