| NPI | 1962193706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: NM CTB-2023-0398) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NM CTB-2023-0398) |
| Enumeration Date | 2023-05-15 |
| Last Update Date | 2024-12-05 |