| NPI | 1912514670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: NC 16618) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC CADC-16144) |
| Enumeration Date | 2020-09-28 |
| Last Update Date | 2026-06-22 |