| NPI | 1962792119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MA 1163) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) |
| Enumeration Date | 2011-04-08 |
| Last Update Date | 2011-04-08 |