| NPI | 1942544630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MO 2016014454) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MO 5866) |
| Enumeration Date | 2012-11-19 |
| Last Update Date | 2020-06-22 |