| NPI | 1912163254 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: NC 7036) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 1297) |
| 101YM0800X Counselor, Mental Health (Licence: NC 7036) | |
| Enumeration Date | 2008-08-06 |
| Last Update Date | 2013-04-04 |