| NPI | 1912235714 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: AZ LAC20472) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: AZ LAC20472) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: AZ LAC20472) | |
| Enumeration Date | 2009-12-07 |
| Last Update Date | 2023-05-05 |