| NPI | 1942481049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA 835) |
| Additional Taxonomies | 251S00000X (Licence: LA 431) |
| 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder (Licence: LA 431) | |
| Enumeration Date | 2007-11-16 |
| Last Update Date | 2024-06-06 |