| NPI | 1962860155 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: NC 12253) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC LCAS-21369) |
| Enumeration Date | 2016-02-03 |
| Last Update Date | 2021-03-15 |