| NPI | 1932308210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 1186) |
| Additional Taxonomies | 164X00000X Licensed Vocational Nurse (Licence: MA 30347) |
| 225C00000X Rehabilitation Counselor (Licence: MA 706) | |
| Enumeration Date | 2007-07-16 |
| Last Update Date | 2007-07-16 |