| NPI | 1891260535 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: WI 5566-125) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 16233-132) |
| Enumeration Date | 2018-10-09 |
| Last Update Date | 2018-10-09 |