| NPI | 1912355736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171M00000X Case Manager/Care Coordinator (Licence: LA 1618) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA 3460) |
| Enumeration Date | 2016-06-02 |
| Last Update Date | 2019-10-01 |