| NPI | 1912096520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: GA 0909) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: GA 00909) |
| 106H00000X Marriage & Family Therapist (Licence: GA 0909) | |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2007-07-09 |