| NPI | 1063783389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: WY 1450) |
| Additional Taxonomies | 101Y00000X Counselor |
| 101YM0800X Counselor Mental Health (Licence: IL 00112777) | |
| Enumeration Date | 2012-01-18 |
| Last Update Date | 2020-02-04 |