| NPI | 1871076299 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: TX 79707) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: TX 14113) |
| Enumeration Date | 2018-09-11 |
| Last Update Date | 2025-04-08 |