| NPI | 1942683974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: CO LPC.00112286) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO ACD.00005111) |
| Enumeration Date | 2015-07-08 |
| Last Update Date | 2016-08-05 |