| NPI | 1821493206 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: CA 123026) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility (Licence: CA 123026) |
| Enumeration Date | 2014-10-28 |
| Last Update Date | 2015-05-13 |