| NPI | 1972856540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: PR 10686) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: PR TAC-II-15-62-0979) |
| Enumeration Date | 2012-10-19 |
| Last Update Date | 2012-10-19 |