| NPI | 1831734730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: VA 0701008785) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: VA 2106) |
| Enumeration Date | 2019-11-14 |
| Last Update Date | 2019-11-14 |