| NPI | 1972748739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: VA 0904006485) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) |
| Enumeration Date | 2008-12-09 |
| Last Update Date | 2023-01-13 |