| NPI | 1902370604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 103K00000X Behavior Analyst |
| Enumeration Date | 2019-01-15 |
| Last Update Date | 2019-06-27 |