| NPI | 1972092328 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KY 274655) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OH CDCA.140638) |
| Enumeration Date | 2018-05-01 |
| Last Update Date | 2022-04-29 |