| NPI | 1073023636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 12883) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 101YM0800X Counselor, Mental Health (Licence: GA 005095) | |
| 101YM0800X Counselor, Mental Health (Licence: GA LPC010470) | |
| Enumeration Date | 2017-10-09 |
| Last Update Date | 2025-11-03 |