| NPI | 1912961442 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO ACD-72) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: CO 1614) |
| Enumeration Date | 2006-04-13 |
| Last Update Date | 2007-07-08 |