| NPI | 1003499302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: MI 6451025263) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2021-05-04 |
| Last Update Date | 2026-09-21 |