| NPI | 1831607175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 101Y00000X Counselor |
| 103TA0400X Psychologist, Addiction (Substance Use Disorder) | |
| Enumeration Date | 2018-01-22 |
| Last Update Date | 2021-09-30 |