| NPI | 1821626672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: FL MH17331) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility |
| Enumeration Date | 2020-03-28 |
| Last Update Date | 2023-04-18 |