| NPI | 1912108010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 1758) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MA 188294) |
| Enumeration Date | 2007-05-29 |
| Last Update Date | 2007-07-08 |