| NPI | 1972910370 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MD AC2107) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MD SC1953) |
| Enumeration Date | 2014-07-17 |
| Last Update Date | 2015-06-11 |