| NPI | 1083755201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: TX 84238) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: KY 0304) |
| Enumeration Date | 2007-02-09 |
| Last Update Date | 2022-03-30 |