| NPI | 1962813782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: CO 7100) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: CO 12695) |
| Enumeration Date | 2014-05-14 |
| Last Update Date | 2019-02-13 |