| NPI | 1063641397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: NC 8977) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: NC 8977) |
| 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: NC 00112424) | |
| 103TR0400X Psychologist Rehabilitation (Licence: NC 00112424) | |
| 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: NC 20131) | |
| Enumeration Date | 2009-07-08 |
| Last Update Date | 2017-03-10 |