| NPI | 1083028088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: MD LC4227) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: MA 8582) |
| Enumeration Date | 2014-06-17 |
| Last Update Date | 2018-04-06 |