| NPI | 1063586840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: IA 2032) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: IA 00265) |
| Enumeration Date | 2006-11-20 |
| Last Update Date | 2025-09-11 |