| NPI | 1932589579 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: WY PPC# 638) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WY LAT #351) |
| Enumeration Date | 2015-06-08 |
| Last Update Date | 2015-06-08 |