| NPI | 1962553313 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: VA 0701005225) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0710100902) |
| Enumeration Date | 2007-01-14 |
| Last Update Date | 2012-06-22 |