| NPI | 1902963739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 649) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: KY 1332) |
| Enumeration Date | 2007-01-02 |
| Last Update Date | 2025-09-11 |