| NPI | 1912057977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: AL 2472) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: AL 2472) |
| 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: AL 2472) | |
| Enumeration Date | 2007-01-11 |
| Last Update Date | 2020-01-23 |