| NPI | 1962626119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: AZ LPC11587) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: AZ LISAC10506) |
| Enumeration Date | 2007-04-12 |
| Last Update Date | 2023-07-25 |