| NPI | 1902054505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: TX 58922) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: TX 58922) |
| Enumeration Date | 2008-09-08 |
| Last Update Date | 2011-06-07 |