| NPI | 1992223200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MT BBH-LAC-LIC-24470) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MT BBH-LAC-LIC-25570) |
| Enumeration Date | 2017-09-07 |
| Last Update Date | 2019-11-19 |