| NPI | 1861964819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: FL 17391) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: FL MCAP100295) |
| Enumeration Date | 2018-12-31 |
| Last Update Date | 2020-07-15 |