| NPI | 1861714404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004783) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: NC 7699) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 7699) | |
| Enumeration Date | 2010-02-24 |
| Last Update Date | 2014-12-31 |