| NPI | 1972202695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 101Y00000X Counselor |
| 320800000X Community Based Residential Treatment Facility, Mental Illness | |
| Enumeration Date | 2023-03-02 |
| Last Update Date | 2024-02-21 |