| NPI | 1891066056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: CO LPC-5584) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: CO ACC-7181) |
| Enumeration Date | 2012-01-19 |
| Last Update Date | 2012-01-19 |