| NPI | 1902275100 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: LA 8018) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA 5115) |
| 171M00000X Case Manager/Care Coordinator (Licence: LA 1525) | |
| 171M00000X Case Manager/Care Coordinator (Licence: LA 1078) | |
| 324500000X Substance Abuse Rehabilitation Facility (Licence: LA 1078) | |
| 324500000X Substance Abuse Rehabilitation Facility (Licence: LA 1525) | |
| Enumeration Date | 2015-09-17 |
| Last Update Date | 2023-02-04 |