| NPI | 1902327018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: TN LDC0000000344) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 016414) |
| Enumeration Date | 2017-06-28 |
| Last Update Date | 2017-06-28 |