| NPI | 1912041591 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: CO 5382-LPC) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO 6616-CACIII) |
| Enumeration Date | 2007-02-16 |
| Last Update Date | 2018-06-18 |