| NPI | 1043784739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: AZ LPC-23000) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2019-01-15 |
| Last Update Date | 2024-06-02 |