| NPI | 1912251661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: WA MC60247370) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: WA CO60283751) |
| Enumeration Date | 2012-11-02 |
| Last Update Date | 2013-04-19 |