| NPI | 1811529886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: VA 0701005942) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0718000296) |
| Enumeration Date | 2020-02-07 |
| Last Update Date | 2020-02-07 |