| NPI | 1962136879 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: WI 11211-125) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 20463-130) |
| Enumeration Date | 2022-07-15 |
| Last Update Date | 2024-07-29 |