| NPI | 1912914169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MA 1066) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MA 2822) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2007-07-08 |