| NPI | 1073260139 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: WA MHCA.MC.70006953) |
| Additional Taxonomies | 106S00000X Behavior Technician (Licence: WA CB61211683) |
| Enumeration Date | 2022-03-08 |
| Last Update Date | 2025-09-29 |