| NPI | 1053661165 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MA 9001) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: OH C.1100180-CR) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-09-16 |
| Last Update Date | 2021-09-13 |