| NPI | 1992096721 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: WY LPC-705) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WY LAT-278) |
| Enumeration Date | 2011-04-27 |
| Last Update Date | 2024-03-26 |