| NPI | 1942611512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 104100000X Social Worker (Licence: IA 090748) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: IA 17106) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: IA 14016) | |
| Enumeration Date | 2014-05-16 |
| Last Update Date | 2023-11-30 |