| NPI | 1912995663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: AZ LISAC-10054) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: AZ LCSW-2345) |
| Enumeration Date | 2005-10-07 |
| Last Update Date | 2007-07-08 |