| NPI | 1962136176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: NM CTB20250181) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NM CTB-2022-0241) |
| Enumeration Date | 2022-07-13 |
| Last Update Date | 2025-07-23 |