| NPI | 1063186500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: MI 6401224884) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: AZ LPC-22795) |
| Enumeration Date | 2021-08-08 |
| Last Update Date | 2025-09-24 |